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Key messages

  • Neonatal nursery environments can provide stressful stimuli to premature and sick infants.
  • Preterm infants are born prior to or during critical periods of brain development.
  • Developmental care aims to implement modifications to the nursery environment and care practices to reduce stress on infants and promote normal neurological development which may help reduce morbidity.
  • Attention to noise, light and positioning, handling and sleep preservation can all help to reduce stress and maximise outcomes.
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    In June 2023, we commenced a project to review and update the Maternity and Neonatal eHandbook guidelines with a view to completion in 2024. Please be aware that pending this review, some of the current guidelines may be out of date. In the meantime, we recommend that you also refer to more contemporaneous evidence.

    Developmental care is an approach to individualise care of infants to maximise neurological development and reduce long-term cognitive and behavioural problems.

    While advances in perinatal care have resulted in decreased mortality rates in preterm neonates, morbidity rates remain significantly high.

    In addition to cerebral palsy, hearing loss, visual impairments and developmental delay, long-term follow-up studies have identified other important neurosensory impairments that may not become evident until preschool or school age such as cognitive and behavioural problems. 

    Preterm infants are born prior to or during critical periods of brain development. The third trimester of fetal development is a period of rapid brain growth and environmental influences such as noise or handling may impact on the developing brain.

    Modifications to the nursery environment and care practices that may reduce morbidity can easily be implemented.

    Goals of developmental care


    The goals of developmental care for the infant are to:

    • reduce stress
    • conserve energy and enhance recovery
    • promote growth and well being
    • protect sleep
    • support emerging behaviours at each stage of neurodevelopmental maturation.


    The goals of developmental care for the family are to:

    • encourage and support parents in the primary caregiver role
    • enhance family emotional and social wellbeing.

    Definition of commonly used terms

    Developmental care

    The process of developmental care involves creating an environment for the infant that minimises stress while providing a developmentally appropriate experience for the infant and family.

    Developmental care refers to interventions that:

    • support the behavioural organisation of the individual infant
    • enhance physiological stability
    • protect sleep rhythms
    • promote growth and maturation.

    Developmental care interventions include:

    • optimal handling and positioning measures
    • reduction of noxious environmental stimuli
    • cue-based care.

    The education and involvement of the parents or carers is critical to the infant’s social, emotional and physical wellbeing and is a crucial factor in the process of family-centred developmental care.

    Newborn Behavioral Observations (NBO)

    The NBO is a structured session designed to help the parent to observe, together with the clinician, their infant's behavioural capacities and to identify the kind of support their infant needs for successful growth and development. It is a relationship-based tool designed to foster the parent-infant relationship.

    It consists of a set of 18 neurobehavioural observations, which describe the infant's capacities and behavioural adaptation from birth to the third month of life. This includes observations of the infant's:

    • capacity to habituate to external light and sound stimuli (sleep protection)
    • the quality of motor tone and activity level
    • capacity for self-regulation (including crying and consolability)
    • visual, auditory and social-interactive capacities and preferences (alertness and responsiveness to human and non-human stimuli.

    Behavioural organisation

    This refers to the ability of the infant to maintain a balance between the five subsystems:

    • autonomic/physiologic
    • motor
    • state organisation
    • attention/interaction
    • self-regulation.

    Examples would include the infant's respiratory status, muscle tone, posture, facial expressions, colour, visceral responses and visual attention.

    How these behaviours are affected by external stimuli, either positive or negative, give information about the infant's ability to cope and organise their responses.

    Cue-based care

    This is a system of care-giving in response to the infant's behavioural cues, including the appropriate provision and modification of sensory stimulation.

    Implementation of developmental care


    Assessment includes the:

    • observation of the infant's behavioural cues - including regular review and modification depending on:
      • condition of the infant
      • infant's level of maturity and gestational age
      • behavioural responses to care
    • nursery environment - including the acoustic environment, aspects of lighting, general layout and furnishings.

    Nursery environment

    Limiting environmental noise

    Monitoring and reducing noise levels should be encouraged. The threshold for cochlear damage for adults is 80-85 decibels, and the newborn will have a lower threshold than this as the immature cochlear is more sensitive. In the nursery noises of this magnitude include closing portholes with a snap or placing bottles on the top of the plexiglass incubator.

    Sound level recommendations for the nursery environment (Australian and New Zealand guidelines) - background noise should not exceed an hourly Leq 40-45 DB (A).

    Noise reduction tips

    • Avoid tapping on or writing on incubators, and close incubator doors and portholes carefully.
    • Have designated quiet times during the day (while also remembering to keep to limits at all times).
    • Encourage staff and visitors to talk quietly, and avoid talking over the infant in an open cot.
    • Move medical and nursing ward rounds away from the bedside or be mindful of speaking quietly.
    • Avoid banging bin lids.
    • Set monitor alarm limits and tone at appropriate levels and try to silence alarms as soon as possible.
    • Purchase equipment with a low noise criterion.
    • Monitor noise levels periodically to identify times and causes of high levels.

    Limiting environmental light

    Constant bright light in the nursery can interfere with natural diurnal rhythms and overstimulate the infant.

    Lighting should be adjustable - the adjustment level range of 100-600 lux is recommended (Australian and NZ guidelines).

    Light reduction tips

    • Maintain appropriate individualised lighting.
    • Use adjustable light levels within each cot bay plus procedure light for observation and procedures.
    • Monitor ambient light levels.
    • Shield infants from bright light with cot covers, eye covers and dimmed lights.
    • Reduce light levels generally in the nursery, maintaining a safe level for accurate clinical observation as necessary.
    • Make use of available natural lighting.


    Infants should be provided with developmentally supportive positioning to optimise musculoskeletal development and behavioral organisation. The primary goals of positioning should include:

    • a variety of symmetrical postures (supine/prone/side lying)
    • trunk flexion, shoulder and hip flexion and adduction
    • shoulder protraction, hands near face
    • neutral alignment of ankles and hips
    • neutral alignment of head and neck whenever possible
    • the use of swaddling or nesting to provide boundaries whilst ensuring a safe sleeping environment
    • regular position changes align with handling and sleep/wake state
    • use head water/gel pillows for infants less than 34 weeks (with respiratory monitoring).

    As infants approach term, they are no longer monitored and are preparing for discharge to home; the Red Nose safe sleeping guidelines must be implemented.

    Parental involvement

    Parents are involved in decisions about interventions where possible. This promotes their understanding of their infant's behaviour and allows them also to practice cue-based care. This allows them to experience positive interactions with their baby and empowers them to recognise behavioural cues and become more confident caring for their baby.

    Nursery practices

    Cue-based care and clustering of cares

    This involves caring for the infant while recognising the behavioural cues or stress responses and providing an appropriate strategy such as timeout or modification of care as appropriate.

    Infants may demonstrate a range of behavioral cues include signs of stability and stress, approach signals, coping/self-calming and time out signals. Staff need to be able to provide or modify care as required and support parents and families to recognise and respond to these cues.

    Clustering of cares encourages a minimum handling approach and protects periods of deep sleep by minimising the number of times an infant needs to be woken up or disturbed.

    If an infant is unable to cope with a particular cluster of care (observation of stress cues) then cluster fewer care procedures next time if possible.

    Sleep protection

    As sleep is the main organisational state of the preterm baby, sleep protection is very important for optimal brain development. Sleep deprivation can have long term effects on growth and development. Understanding the infant's unique sleep/wake cycle and providing cued based and clustered cares enables longer periods of uninterrupted sleep.

    Stressful or painful procedures

    Minimise painful procedures and provide appropriate pain relief measures.

    During these procedures the use of some comforting techniques can reduce stress responses.

    Comforting techniques include:

    • non-nutritive sucking (dummy, cotton bud with breast milk or sucrose)
    • containment of infant's arms and or legs (swaddle or gently holding hands together on chest and/or hold legs tucked up)
    • grasping a finger.

    Feeding support

    Provide support for breastfeeding or alternatives as required with the emphasis again on individualised family-centred care.

    Follow the infant's cues and pace the feeds, according to the infant’s capacity to organise sucking, swallowing and breathing.

    Non-nutritive sucking 

    Non-nutritive sucking provides opportunity for self-calming and is helpful in the transition to suck feeds. Offer the infant opportunities to suck on a dummy/pacifier or other suitable object, such as a (gloved) finger or their own hands and fingers during painful procedures, tube feeding and when the infant is showing signs of oral readiness.

    Staffing practices

    Provide continuity of caregivers whenever possible. Develop caregiver groups for longer stay infants.


    Handling techniques include the following:

    • Handle infants in ways that minimise stress and uncontrolled responses.
    • Contain the infant using hands or a light swaddle to keep them in a flexed and contained position.
    • Move infant slowly and keep them in contact with the supporting surface whenever possible.
    • Introduce touch slowly and allow time for the infant to respond and adjust to a change in position.

    Ensure opportunity for positive touch is given to the infant by parents and carers.

    Noxious stimuli

    Minimise the infant’s exposure to noxious stimuli such as strong fragrances, open alcohol swabs outside the incubator, clinical procedures and adhere to lighting and noise guidelines.

    Kangaroo care

    Provide opportunities for kangaroo care when possible. Kangaroo care is early, prolonged and continuous skin-to-skin contact between a parent and a low-birthweight infant. Kangaroo care has been shown to:

    • improve state organisation
    • reduce oxygen needs, improve respiratory patterns
    • reduce apnoeas and bradycardias
    • improve thermal regulation
    • enhance parent infant bonding and a parental sense of competence
    • enhance cognitive and motor development.

    Kangaroo care can be used to facilitate early breast contact/feeding or be used for the simple pleasure of closeness, attachment and bonding.

    More information

    • Newborn Behavioural Observations (NBO) training, the Royal Women's Hospital.
    • Developmental Care: NISC, the Royal Women's Hospital.
    • Family and developmental care guidelines, King Edward Memorial Hospital.
    • Auckland District Health Board guidelines for developmental care 27 weeks to 37 plus weeks corrected gestation.
    • Abbott, J & Isreal C, Developmental care - mapping the way forward in the UK: a BLISS initiative. Infant. 2008: Vol 3 Issue 4, 80-84.
    • Als H, Duffy FH, McAnulty GB, Rivkin MJ, Vajapeyam S, Mulkern RV, et al. Early experience alters brain function and structure. Pediatrics. 2004;113:846-857.
    • Graven SN. The full-term and premature newborn. Sound and the developing infant in the NICU: conclusions and recommendations for care. J Perinatol. 2000;20:S88-S93.
    • Saigal S, Doyle LW. An overview of mortality and sequelae of preterm birth from infancy to adulthood. Lancet. 2008;371:261-269.
    • Symington A, Pinelli J. Developmental care for promoting development and preventing morbidity in preterm infants.[update in Cochrane Database Syst Rev. 2003;(4):CD001814; PMID: 14583939][update of Cochrane Database Syst Rev. 2000;(4):CD001814; PMID: 11034730]. 2003;4:CD001814, 002001.
    • Aucott S, Donohue PK, Atkins E, Allen MC. Neurodevelopmental care in the NICU. Mental Retardation and Developmental Disabilities. 2002;8:298-308.
    • White R. Recommended standards for newborn ICU design. J Perinatol. 2006;26:S2-S18.
    • Feldman R, Eidelman AI. Skin-to-skin contact (kangaroo care) accelerates autonomic and neurobehavioural maturation in preterm infants. Dev Med Child Neurol. 2003;45:274-281. 10 Pinelli J, Symington A. Non-nutritive sucking for promoting physiologic stability and nutrition in preterm infants (Review) Cochrane Database of Systematic Reviews. 2005;4: 1-24.
    • Mercy Hospital for Women (2014) Developmental care Clinical Guideline.

    Get in touch

    Clinical Guidance Team
    Safer Care Victoria

    Version history

    First published: July 2017
    Review by: July 2020

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