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Table of Contents
Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 99-106

Early neurodevelopmental supportive care: Approach to enhance the neurodevelopmental outcome in premature and low birth weight infant

Department of Pediatric Nursing, College of Nursing, AIIMS, Jodhpur, Rajasthan, India

Date of Submission26-Aug-2021
Date of Decision17-Sep-2021
Date of Acceptance20-Jan-2022
Date of Web Publication15-Mar-2022

Correspondence Address:
Mr. V A Raghu
College of Nursing, AIIMS, Jodhpur, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jihs.jihs_24_21

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The mother's womb is a favorable environment for fetal growth and development. The extrauterine environment is traumatic to tiny and premature infants for survival, and the environment in neonatal intensive care unit (NICU) does not support the optimal brain growth and development of a premature infant. The survived premature and low birth infants are at risk to develop lifetime disabilities and impaired neurodevelopment outcomes. The aim of the review was to highlight the component of early neurodevelopmental supportive care used in NICU to enhance the neurodevelopment of preterm and low birth weight. The researcher used electronic databases – PubMed, MEDLINE, CINAHL, and Google Scholar electronic databases for searching the literature. Poor developmental outcome impacts directly on the long-term development and functionality during infancy, childhood, and adulthood. The early neurodevelopmental supportive care in NICU and in early infancy period could improve the neurodevelopmental outcome. Neurodevelopmental supportive care is an approach that uses a wide variety of medical and nursing interventions that focus to decrease the stress of preterm neonates in NICUs and support optimum neuronal growth as well neurobehavioral development of an infant. Nurturing a child by understanding their needs and responding sensitively helps to protect developing brains from undue stress and support optimal cognitive and behavioral development.

Keywords: Cognitive, neurodevelopment, neurodevelopmental supportive care, neonatal intensive care unit, premature

How to cite this article:
Raghu V A, Vatsa M. Early neurodevelopmental supportive care: Approach to enhance the neurodevelopmental outcome in premature and low birth weight infant. J Integr Health Sci 2021;9:99-106

How to cite this URL:
Raghu V A, Vatsa M. Early neurodevelopmental supportive care: Approach to enhance the neurodevelopmental outcome in premature and low birth weight infant. J Integr Health Sci [serial online] 2021 [cited 2023 Jun 5];9:99-106. Available from: https://www.jihs.in/text.asp?2021/9/2/99/339651

  Introduction Top

The uterus is an optimal environment for fetal development from conception to birth. During intrauterine life, all systems develop and become mature enough to enable the baby to survive in an extrauterine environment after birth.[1] The extrauterine environment is not the same as the intrauterine environment, and neonates, especially premature infants, are continuously exposed to a stressful environment. The extrauterine environment in the neonatal intensive care unit (NICU) does not support normal growth and development and makes the preterm infant more susceptible to brain injury.[2] The sensory development is affected as there is a disruption in development of brain structure in premature neonates.[3] Due to these complications, the survived premature neonates are at risk for developing lifetime disabilities such as cerebral palsy (CP), cognitive impairment, language impairment, learning, and behavioral problems.[4]

It is fact that there is an increase in the survival rate of preterm infants over the last decade because of an improvement in perinatal care, and it led to a significant decrease in the mortality rate among preterm infants worldwide. However, there has not been a corresponding improvement in the long-term developmental outcomes of preterm infants. Poor developmental outcome impacts directly on the long-term development and functionality during infancy, childhood, and adulthood. The premature neonate faces long-term disabilities such as neurodevelopmental delay, CP, visual problem, and postural deformities. Poor attention, low IQ, and behavioral problems are evident in prematurely born children during school age. Therefore, improving the developmental outcome is important as equally as the survival of premature neonates.[4]

Neurodevelopment is a dynamic inter-relationship between genetic, brain, cognitive, emotional, and behavioral processes across the developmental lifespan. Significant and persistent disruption to this dynamic process through environmental and genetic risk can lead to neurodevelopmental disorders (NDDs) and disability.[5] NDDs comprise a spectrum of disorders that include autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), developmental coordination disorder (DCD, also called dyspraxia), developmental language disorder, dyscalculia, dyslexia, intellectual disability, and tic disorders.[5]

Arora et al. conducted population-based burden estimates of neurodevelopmental disorder across five regions in India among 3964 children aged 2–9 years. The site-specific prevalence of any of seven NDDs in 2–<6-year-olds ranged between 2.9% and 18.7% and for any of nine NDDs in the 6–9-year-old children from 6.5% to 18.5%. About one-fifth of these children had two or more NDDs. Hearing impairment and intellectual disability were the most common NDDs. The risk factors for childhood NDDs were children with a history of delivery at home, perinatal asphyxia, neonatal illness requiring hospitalization, neurological/brain infections, low birth weight, and prematurity and stunting.[6]

Preterm birth is the leading cause of neurobehavioral impairment and disability. The neurobehavioral impairment in preterm infants ranges from 22% to 55% compared with 7% in full terms with the same age.[7] The NDDs linked with prematurity include CP especially spastic diplegia, intellectual disability, hearing loss, and visual impairment due to retinopathy of prematurity (ROP). The neurodevelopmental disorder that is seen in children born prematurely is mainly due to insult to the brain during pregnancy or at the time birth, or any lesion inside the developing brain.[8]

A meta-analysis revealed that the very low birth weight (VLBW) infants have a 10% low cognitive score compared to matched control infants because of poor attention, behavioral problem, visual, motor, and language problems.[9] A study conducted by Kim et al. shows that 15 of 88 (17%) of the VLBW children had a below-average Full Scale Intelligence Quotient (FSIQ) (<85). VLBW with intrauterine growth restriction is associated with poor cognitive outcomes at the mean age of 4.5 years.[10] A meta-analysis conducted by Upadhyay et al. using 99 articles (n = 5999) revealed that children <10 years of age born low birth weight had lower cognitive and motor scores compared to children with normal birth weight children. The children who had a birth weight <2000 g had much lower cognitive and motor scores.[11]

The United Nations General Assembly and Agenda for Sustainable Development contemplate childhood disability as an integral part of the global development agenda.[12] The early neurodevelopment supportive care in NICU and during the early infant period could help in reducing the neurodevelopmental disorder in later life of the child.[13] Neurodevelopmental supportive care is an approach that uses an intervention which focuses on improving the cognitive and behavioral development. Neurodevelopmental supportive care comprises a variety of approaches such as environmental modification in NICU which are known to cause stress, clustering of care, family-centered care, nonnutritive sucking, nesting, swaddling, early initiation of breastfeeding, pain management, general motor containment, and kangaroo care.[14]

Spittle et al. conducted a systematic review with 12 randomized controlled trials (RCTs) to assess the effectiveness of an early developmental intervention program. A meta-analysis concluded that early interventions improved cognitive outcomes at infancy (P < 0.001) and IQ at preschool age (P < 0.001). The meta-analysis concluded that the early developmental interventions were beneficial at infancy only.[15]

The Lee and Lee conducted study among 85 premature infants with birth weight <2.5 kg, showed significant effect of neurodevelopmental intervention in improving the body weight, head circumference and cognitive outcome (p=0.05).[16] A prospective, controlled trial conducted by Meena et al. showed better neurologic and developmental outcomes in interventional group.[17]

The above research findings suggest that early neurodevelopmental intervention improves the neurodevelopmental outcome in premature and low birth infants. Nurturing a child by understanding their needs and responding sensitively helps to protect children's brains from stress and support optimal brain growth. Ensuring that parents, caregivers, and early childhood care providers have the resources and skills to provide safe, stable, nurturing, and stimulating care is an important public health goal to reduce neurodevelopmental disorder in later life.[18] This review article highlights theories and models of neurodevelopment, developmentally supportive care to improve the neurodevelopmental outcome in premature and low birth infants.

  Theories of Infant Development Top

Synactive theory of infant development

The synactive theory of infant development is a theoretical model. It gives a basis for understanding and evaluating the individual infant's behavioral and mental development. This model focuses on the continuous and dynamic interaction of various subsystems within the infant. The subsystems are autonomic subsystem which is expressed in the pattern of respiration (e.g., fast, slow, and pauses) color changes (e.g., pink, pale, and red), neurological indicators (e.g., seizures and tremulousness), and visceral cues such as bowel movements, gagging, and hiccupping. Motor subsystem is observable through the tone, posture, and movement patterns of the infant. State and attention/interaction subsystem: State subsystem is a way of categorizing levels of central nervous system (CNS) sleep and wakefulness state. Self-regulatory subsystem is represented through the observable strategies the infant uses (self-regulation) in maintaining a balanced, relatively stable, and relaxed state. According to synactive theory, the infant is continuously interacting with subsystems and with the environment, and these subsystems continuously interact and influence each other in intrauterine life. Therefore, it is called synactive development of a fetus. This theory forms the basis for individualized developmental supportive care of infant- and family-centered care. The health-care provider and caregiver are educated and trained to be sensitive to each subsystem's stressful behavior of an infant. Therefore, the caregiver uses these observation findings to modify the environment and facilitate the infant's organization of subsystems and well-being.[19]

Transactional models of development

Transaction model emphasizes how the environment and parental behavior influence the development of an infant. This model aids to understand the importance of bidirectional and interactional processes that occur over time between infants and parents. This model considers the effects of individual and environmental factors on development as distinct from one another. This theory assumed that undesirable behavior in children was a result of poor parenting behaviors. This model explains that the various levels of situations can interact with one another and either directly or indirectly affect child development, for example, poor maternal social support leading to insecure attachment. However, secure attachment between mother and child will be promoted when mother respond to their children with positive means and when children receive adequate maternal and social support.

This model also focused on the importance of various environmental factors on the development of infants. The family environment is of key importance during infancy and early childhood; interactions with teachers and friends take on collective importance in later childhood and adolescence. In early childhood, punitive and inadequate parenting practices and behavior often cause the child to exhibit difficult temperament and noncompliant behavior; over time, if the parents become too harsh toward the child, his behavior becomes more noncompliant and aggressive. The child who has aggressive behavior may impact the student–teacher relationship in the school environment, and it leads to poor academic performance. This also can cause poor peer interactions that result in peer rejection and poor self-esteem. Research also supported that the role of transactional processes (e.g., disrupting parent–child interactions and peer functioning) with depression and ADHD in children.[20]

  Neurodevelopment Top

Neurodevelopment is the brain's ability to develop the neurological pathways responsible for the normal functioning of the brain's ability to learn, focus, and develop memories and social skills effectively.

Neurodevelopment of the brain and CNS is often termed psychomotor development and is usually divided into four main domains: gross and fine motor skills, speech and language, social and personal activities of daily living, and performance and cognition.[18]

Neurodevelopmental delay

Global developmental delay refers to a significant delay in two or more of the four main developmental domains as cognitive, motor, language, and affective domains. Significant developmental delay is defined as performance two or more standard deviations below the mean on age-appropriate standardized norm-referenced testing.[21] Developmental delay occurs when a child exhibits a significant delay in the acquisition of milestones or skills in one or more domains of development (i.e., gross motor, fine motor, speech/language, cognitive, personal/social, or activities of daily living).[21]

Neurodevelopmental disorder

NDDs comprise a major disorder affecting social, communication, activity, attention, motor coordination and literacy, and numerical skills.[21]

In India, about 26 million infants are born annually and India has shown a significant decline in neonatal, infant, and under-five mortality rates, and improved survival of high-risk infants is likely to develop NDDs in later life. The WHO report shows around 9 million infants suffering from the developmental delay due to prematurity.[22]

Bellman et al., 2013, study report a 1%–3% prevalence of global DD in children, while the global prevalence of ASDs was estimated to be 1 in 132 (Baxter et al., 2015). The estimated crude prevalence rate of current ADHD in India was 5.8%, and across the world, the prevalence is between 5.29% and 7.1% in children and adolescents.[23] Seventy-five to ninety percent of the affected people have a mild intellectual disability, and it affects 2%–3% of the general population.[24]

A communication disorder is a problem with hearing, language, and speech, and it may range from mild to profound. It is estimated that nearly one in 10 American children has some type of communication disorder. Language disorder is characterized by difficulties in learning and using language, which is caused by problems with vocabulary, with grammar, and with putting sentences together in a proper manner.[25] A child with hearing disorder has problem with production and comprehension of language.[25] ASD is a developmental disorder. It is characterized by impairments in social interaction and communication. The Centers for Disease Control and Prevention (CDC) American study reports that 1 in 59 United states children affected by ASD. A child with specific learning disabilities will have problems with learning basic skills such as reading, writing, and maths.[26]

The motor disorders include DCD and tic disorders. DCD starts in early childhood and which leads to gaucheness and impaired motor coordination and it is characterized by deficits in the acquisition and execution of coordinated motor skills as well as slowness and inaccuracy of performance of motor skills (e.g., catching an object, using scissors, or participating in sports). Tic disorders are characterized by the presence of motor or vocal tics, which are sudden, rapid, nonrhythmic motor movement or vocalization.[27],[28]

CP is the most common movement disorder in children. It occurs in about 2.1 per 1000 live births. A CP is a group of disorders that affect balance, movement, and muscle tone. There are 17 million people across the world living with CP. Another 350 million people are closely connected to a child or adult with CP. It is the most common physical disability in childhood. CP is a permanent disability that affects movement. CDC estimates that an average of 1 in 345 children in the U. S. have CP.[29]

Hansen et al. conducted a study to assess the prevalence rate of neurodevelopmental disorder in Norway in 2018 among referred children aged between 7 and 13 years. The result shows that one or more neurodevelopment disorder was diagnosed in 226 children (55.5%; 69.9% of boys). ADHD (44.5%; 68.5% of boys), TD (17.7%; 77.8% of boys), and ASD (6.1%; 76% of boys) were noted, and 49 (21.7%) children had more than one ND.[30]

NDDs are diagnosed by evaluating the presence of characteristic symptoms or behaviors in a child, especially when the parents raise concern over the child's development. Age-appropriate developmental screening tools are used to identify the neurodevelopmental delay.[31] The poor identification of children with developmental disabilities is a matter of concern because early detection and initiation of treatment have been shown to improve child outcomes for DD.

  Models of Neurodevelopmental Supportive Care Top

The neonatal integrative developmental care model

Neuroprotective strategies are capable of preventing neuronal cell death and are used to support the developing brain. These interventions decrease neuronal cell death and allow to heal fast after brain damage through developing new connections and pathways for functionality. There are seven vital interventions in the neonatal integrative developmental care model which provide the framework for medical and nursing care in NICU. The seven core measures include healing environment, family-centered care, positioning and handling of the neonate, protection of sleep, reducing the stress and pain, protection of skin from damage, and optimum nutrition. All seven core measures are encircled by skin-to-skin contact. Therefore, it is considered a basic approach for the care of neonates in the NICU. Kangaroo mother care (KMC) is an essential component of neuroprotective intervention because it is considered an ideal environment and ideal place to care the premature neonates. Parent and infant relationship is an essential measure in this model because it is highly significant for the development of the infant sensory system. Neuroprotective interventions of this model are used as an approach to support normal brain growth and to promote normal cognitive, physical, and emotional development, as well to prevent long-term disabilities.[32]

Newborn individualized developmental care and assessment program

In traditional care, an infant is considered a patient, and parents are considered a visitor. But, in the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) approach, infants are considered as a unique individual and they are supported and fostered by their parents. Infants' parents are considered key nurturers, advocates, supporters, and caregivers as well as collaborators in making decisions related to infant care in the nursery.

NIDCAP stands for Newborn Individualized Developmental Care and Assessment Program. The NIDCAP approach was introduced by Dr. Heidelise Als of Harvard Medical School and Boston Children Hospital and his colleagues as a way to understand infant behavior in a nursery. They thought that this approach would help to understand what the infant expects for comfort, well-being, and feeling sense of security. NIDCAP is a kind of both philosophical and practical approaches in delivering developmentally appropriate individualized care.

NIDCAP model explains the relationship of training and support system to change the traditional clinical practice into consistent highly integrated NIDCAP care for an infant. This model also depicts the role and responsibilities and support opportunities offer to clinicians and staff engaged in NIDCAP care. The NIDCAP approach supports infant healthy development, enhances strengths, and minimizes stress for infants, family, and staff who look after the infant. The NIDCAP approach is individualized, family centered and uses a relationship-based approach that produces measurable results.[33],[34]

Three RCTs were conducted to assess the effects of the implementation of NIDCAP on VLBW infants. The result shows a mean difference in length of ventilation of 25.7 days in favor of the intervention.[35] There is a Cochrane review on implementation of NIDCAP which also revealed that less relative risk of moderate-severe pulmonary radiographic findings (respiratory rate = 0.34) and intraventricular hemorrhages of grade 3 or more (RR = 0.51) in NIDCAP infant groups.[35] A recent RCT with 5-year follow-up study conducted in Swedish showed a significant impact on the NIDCAP group on surviving without development of abnormal behavior (odds ratio [OR] = 19.9) and mental retardation (OR = 3.5), and the OR of survival without overall disability was 14.7.[36]

  Early Neurodevelopmental Supportive Care Top

Most of the infants born with preterm and low birth weight babies will have associated health problems and need NICU admission for intensive medical and nursing care. Current NICU practices are less intrusive and use the highest technology which improves the survival rate, but these strategies are not enough for the healthy development of the brain. The NICU environment has adverse developmental effects. The professionals who are working in NICU are encouraged to establish an in utero environment to promote normal growth and development in the preterm very low birth weight infant.

  The component of Early Neurodevelopmental Supportive Care Top

Individualized care

Individualized developmental supportive care is based on the relationship between the infant, parents, and staff. Individualized care refers to planning the nursing and medical intervention based on the infants' cues and behaviors communicated during the interaction with the infant. Integrating age-appropriate and individualized developmental care can enhance the development of the preterm infant, and it can also enhance the parenting skills and abilities in providing care to their babies. The nurse should perform a systematic assessment to determine readiness for intervention and document the unique cues and behaviors including the likes and dislikes of an infant and plan the nursing intervention based on likes and dislikes. It is better to assign the primary care nurse to provide consistent nurturing and rewarding nursing care to the infant.

Family-centered care

Family-centered care is a professional partnership between parents and health-care workers that supports the parent's engrossment with their child. The active partnership of parents and family members in planning and implementation of infant care offer opportunities to understand the infant cues, and this helps the family members and professional to plan the delivery of individualized care even in the highly technical NICU environment. The goal of family-centered care is to support and empower the parents to develop nursing care skills and techniques. Family-centered care decreases parental stress and guilty feeling. It also helps the parents to adapt parenting behavior and assist in assessment of infant growth and development. In family-centered care, the parents are allowed to see the baby, opportunities are provided to touch, hold, and talk to their infants. The NICU personnel can plan the feeding, bathing, and KMC activities for the parents and emphasize on parenting skills by involvement of parents in planning and implementing nursing care. Open and honest communication among all members of the health-care team is encouraged. Information is shared in a timely and supportive manner with the parents, and a nonjudgmental atmosphere is created in which parents can openly express feelings and concerns.


Positioning the preterm infant same as the fetal position offers good physical and motor development, promotes sleep quality, offers relaxation, enhances self-organization (feels safe and secure), conserves energy and body heat, and optimizes respiratory function. The infant has to be placed in a contained, flexed posture with firm boundaries, midline neck position, and shoulder protracted. This position mimics the intrauterine condition. Predominantly, preterm infants are positioned in a supine position, and studies proved that the prone position in preterm infants is developmentally appropriate as it enhances effective breathing and improves oxygenation.[36],[37],[38]

Handling techniques

Premature neonates are very delicate; they must be handled carefully with appropriate touch and movement. Nesting and swaddling help to promote sleep and provide comfortable position. Appropriate handling technique supports self-regulation. The quiet and soothing environment in NICU, individualized care, and clustering of care promote the state regulation, minimize the stress, and promote the stable relaxation.

Clustered care refers to all the needed interventions, and care is provided together when the infant is completely awake. The clustered care promotes the undisturbed sleep and decreases the infant energy expenditure, decreases stress, and enhances the maturation of sleep states. Swaddling mimics the intrauterine position. Swaddling refers to wrapping the baby with banket while maintaining limb flexion position. It is evident that swaddling reduces the physiologic distress and improves the motor organization and effective self-regulatory abilities. Lotas and Walden state that generalized motoric containment of the preterm infant's arms and legs closed to the body while in a side-lying or supine position resulted in significantly lower mean heart rates, shorter mean crying, and sleep disruption times, and fewer sleep-state changes after painful procedures. Supporting the neonates before, during, and after the daily routine care promotes the self-regulation and reduces the stress. The best approach to enhance the self-regulation is use of nonnutritive sucking, grasping, and swaddling during any interventions.[37],[38]

Kangaroo mother care as a multimodal sensory stimulation technique

KMC is a skin-to-skin contact which involves keeping the infant between the mother's breast in an upright position at least for an hour initially and promoting exclusive breastfeeding. KMC is initiated when the neonates are hemodynamically stable.[31] KMC provides tactile stimulation as the baby is in prolonged skin-to-skin contact, swaddled positioning of the infant offers kinesthetic-proprioceptive stimulation; breast milk offers olfactory-gustatory stimulation; sucking the nipples provides oro-motor stimulation, and maternal voice such as heartbeat and maternal talk provide auditory stimulation. Skin-to-skin contact improves state regulation and maintains body temperature. KMC promotes bonding between infant and mother and enhances maternal attachment which is essential for emotional and social development.[39],[40] Auditory, Tactile, Vestibular, and Visual (ATVV) and Rice Infant Sensory Stimulation (RISS) are other multimodal sensory stimulation techniques. The research evidence suggests the positive effect of ATVV intervention on neurodevelopment and decreased length of hospitalization. RISS intervention comprises mother talking to child, massaging, rocking, and eye contact. The RISS intervention promotes the mother–infant interaction. The home-based early stimulation model carried out by the mother has shown a beneficial effect to improve the developmental status of at-risk neonates during infancy.[41],[42]

Multisensory stimulation

Different multisensory stimulations are practiced in NICU for neuromuscular development of the premature infant. Different stimulation includes ATVV stimulation.[43]

Tactile stimulation

The intrauterine environment provides a rich sensory experience to a fetus as it is immersed in the amniotic fluid. A premature infant is deprived of tactile stimulation during a NICU stay. The gentle touch and containment can be provided by the mother, caregivers, and professionals to provide tactile stimulation. This will contribute to improved growth and shorter hospital stay.[44]

Vestibular stimulation

The most effective way to provide vestibular stimulation is moving the infant's whole body very slowly while keeping the body and head aligned and limbs tucked. The rocking or bouncing movement should be reduced as it causes overstimulation. Vestibular stimulation facilitates quiet sleep. Walking with the baby may also provide vestibular-proprioceptive stimuli.[45]

Kinesthetic stimulation

It is provided when the baby is in a supine position, both the head and body of the baby are slowly moved up and down and passive movement of extremities. The water beds and sheepskin are used to provide kinesthetic stimulation. However, new studies suggest the use of memory foam mattresses in place of waterbeds as it is overstimulating. Kinesthetic stimulations help to gain daily weight and improve the quality of sleep and self-organized behavior.[46]

Moyer-Mileur et al. reported that the range of motion activities and gentle massage of extremities has a positive effect on increasing the weight gain and bone mineral density.[47] A systematic review suggests that there are few evidences which depict the effect of physical activity on short-term weight gain and bone mineralization but lack evidence for long-term effects in preterm infants.[48]

Auditory stimulation

Mother voice is the best auditory stimulation for a premature infant. Family-centered care and KMC are practiced to provide auditory stimulation. Follow all the NICU guidelines to decrease the overall noise level. Maintain the NICU noise level below 45 dB in which the infant can pick up the mother's voice.[46]

Visual stimulation

In NICU, premature infants need to be exposed to rhythmic low-level ambient lights to allow the circadian rhythm which facilitates the sleep cycle. An infant needs ambient light without exposure to direct light up to 40 weeks of corrected age and after child can be exposed to a different color for visual stimulation.

A meta-analysis reports that the cycled light tends to improve the weight gain and shorter length of hospitalization and reduce the incidence of ROP as compared to continuous bright light.[49]

Olfactory-gustatory stimulation

Preterm infants need to be fed by alternative methods because of incoordination of sucking and swallowing reflexes, due to which the preterm infant is deprived of normal sensory stimulation. The prolonged duration of alternative feeding methods can affect the normal sucking behavior. Nonnutritive sucking is encouraged to fasten the transition from an alternative method to breastfeeding. Breast milk offers olfactory and gustatory stimulation to an infant.[50]

Infant massage

Infant skin is very delicate and has superficial nerve endings. The massage is provided with gentle stroke with two fingers flat on body. The gentle massaging enhances the mental development cognitive performance, sucking behavior and improve the physiological state in the neonatal period. Many studies reported the beneficial effect of massaging with or without kinesthetic stimulation on weight gain, state regulation, cognitive score and stress behavior in neonates. however, there is lack of strong evidence by the reported studies.[51]

Oro-motor stimulation

The oro-motor stimulation improves the transition from alternative feeding to breastfeeding in an infant who is on a prolonged alternative method. An RCT on the effect of oro-motor intervention reports improved transition, increased feeding tolerance, and shortened hospital stay.[52]

A study conducted by Zeraati et al. revealed that the multisensory stimulation has significant effects on the development of neuromuscular in premature infants (P = 0.001).[53]

Pain management

Pain management is vital in development of premature brain. The research evidence suggests that the nonpharmacological methods such as nonnutritive sucking, the administration of sucrose, swaddling, and containment, and the elimination of environmental sound and light help in reducing the pain in neonates. Oral sucrose is effective in decreasing heart, crying, and pain scores. The acute pain is managed with local anesthetic drug and chronic pain in neonate is managed with acetaminophen, morphine and sedatives.[54]

A systematic review conducted by Pillai Riddell et al. reported strong evidence to support the practice of KMC, nonnutritive sucking, swaddling, facilitated sucking, and containment as a nonpharmacological method for pain management.[54] Bellieni et al. report that multisensorial stimulation technique can be used as a means of the pain management tool during heel prick in preterm infants.[55]


Breast milk is the golden diet for premature infant, as early as possible, breastfeeding should be initiated in NICU. It has many beneficial effects. Breastfeeding allows maternal involvement in feeding and improves the maternal confidence, facilitates mother–infant interaction, and enhances the bonding, which is pivotal for the socioemotional development of the infant.[56]

Management of the external environment

The NICU environment is determinantal to the sensory development of premature neonates. The nervous system of the VLBW preterm neonate is highly sensitive and vulnerable to sensory input, therefore, the NICU environmental stimuli may result in overloading and stressful to the preterm neonates.[58] To maintain the ideal NICU environment for supporting brain growth, the noise level should be <45 dB and light intensity should not be more than a 100-foot candle. Provide cycled light from 32-week gestation or when the preterm infant begins to differentiate sleep and wake cycles. This will help to develop diurnal rhythms. Maintain the NICU environment in a way that infants can pick up the mother's voice. The NICU environment modification measures include the use of incubator covers, pad doors, keeping the alarm at a very low level, avoiding the use of cell phones, and low conversation. Use the natural light in NICU whenever possible and avoid exposure direct bright light.[57]

A multidisciplinary approach

A multidisciplinary approach to developmental care requires the teamwork of all health-care professionals, and knowledge is shared among the various personnel involved in the care of a preterm infant. All should be familiar with preterm infant's developmental care plan and should participate in its application.[57]

  Summary Top

The present review found that many of the studies report positive effects of early developmental supportive care on improving the neurodevelopmental outcomes, physiological and behavioral states. This review tried to summarize the evidence-based early neurodevelopmental intervention for premature and low birth weight babies. The neurodevelopmental interventions are cost-effective and can be practiced in all settings even in resource-limited countries. Thus, it needs only training of health-care personnel on early developmental care interventions for implementation in NICU. This would help the preterm neonates to adapt with the environmental challenges in NICU and beyond the hospital stay. The NICU environment modification and adapting the early neurodevelopmental intervention practice in NICU as well as in early infancy period would help to improve the neurodevelopmental outcome of premature neonates.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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