Optimal developmental care for babies on the Neonatal Unit (NNU) and Transitional Care - Guideline for supporting

Publication: 21/11/2018  
Next review: 10/02/2025  
Clinical Guideline
ID: 5788 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2022  


This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for supporting optimal developmental care for babies on the Neonatal Unit (NNU) and Transitional Care

1.0 Summary

A baby’s environment is critical to their autonomic stability, growth and development. It is acknowledged that neurodevelopmental, sensory, behavioral and emotional outcomes are often poorer in preterm babies including increased risk for

  • Abuse and bullying
  • anxiety and depression,
  • autistic spectrum disorders,
  • cerebral palsy
  • eating disorders
  • hearing loss
  • language delay
  • poor motor coordination,
  • visual impairment1,18

Developmental care strategies have been designed to reduce the detrimental effects of the environment of the NNU for preterm or unwell babies. These strategies include a broad range of nursing and parental interventions which aim to provide an appropriate environment for each individual infant during this critical period in his or her neural development.

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2.0 Aims and Objectives

This guideline will provide evidence-based recommendations for appropriate delivery of developmental care strategies on the NNU

The guideline aims to

  • reduce infant stress and promote autonomic stability during cares or interventions,
  • protect sleep,
  • ensure appropriate postural support
  • ensure appropriate lighting
  • ensure appropriate sound exposure
  • ensure appropriate exposure to smell and taste

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3.0 Developmental Care Guidnance

3.1 Delivering cares or interventions

3.1.1 Background:

For a preterm baby, being born early means over exposure to stressful external stimuli and necessary cares or interventions such as nappy changes, cannulation, blood sampling, position changes etc. which have the potential to have a long term negative impact on them. This is also true for any babies requiring neonatal care. These essential procedures can cause already fragile babies to become unstable, which can present clinically as changes in their colour, oxygen requirement, physiological observations and disturbances to gastrointestinal function. Additionally, it may cause pain as well as disturbance to sleep, growth and thermoregulation.  A baby may require care or interventions multiple times a day and even multiple times an hour, increasing the potential for negative impacts on long term neurodevelopment.

Parents are in a good position to provide support for their baby during this time as they can provide consistent and responsive care. Increased parental input in this manner can support better neurodevelopmental and behavioural outcomes as they can provide individualised, appropriate and prompt developmental support.

NB: The medical needs of the baby take priority; developmental care should not be favoured over patient safety, especially in an emergency situation. However, in many situations, a developmentally focused approach can be adopted.

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3.1.2 Principles/Aim:

  • To maintain stability and homeostasis
  • To provide individualised care based on observation and response to the baby’s stress/disengagement or comfort/approach cues (see table for cues to observe for)
  • To prevent unnecessary interventions
  • To protect sleep
  • To minimise potential short and long term negative impacts during caregiving
  • Individualise care dependant on each infant’s gestation, corrected age, condition and dependency
  • Support parents to provide consistent and responsive care for their baby

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3.1.3 Method and Rationale



Wherever possible, do not deliver care and perform interventions during periods of sleep

Essential neurodevelopment occurs during sleep and disturbing sleep cycles can affect this.

Observe for signs of stress or instability by watching for physiological, motor and behavioural cues

Commencing cares or interventions on a baby showing distress/disengagement  cues will often result in increased autonomic instability during the procedure.

Pacing and following cues to deliver care is less harmful than clustering cares. It is less disruptive to pause and comfort to allow readjustment and stabilisation throughout caregiving and intervention than to “get it over with quickly”

Prepare well, ensure all equipment needed is available

Minimises the time required to deliver care/procedure and ensures the baby is not left alone uncomforted while forgotten equipment is gathered

Minimise harmful background stimuli such as light, noise, cold

Preterm babies can become overwhelmed and physiologically unstable if exposed to excessive external stimuli. This gives the baby the best chance to cope with the intervention

Approach the baby slowly and gently, giving time for them to prepare for the intervention

Allows baby time to transition and prepare for disturbance

Use positive touch such as comfort holding for painful procedures and promote non-nutritive sucking with EBM (Expressed Breast Milk) or sucrose. (refer to procedural pain guideline)

Minimise any pain responses and reduces stress or autonomic instability

Promote a midline position, ideally side-lying with feet together, throughout cares, transfers and painful procedures and facilitate self-regulation behaviour such as hands to mouth, sucking, foot bracing

Promote parental awareness of comfort behaviour and cues, and involve them in discussions regarding baby’s preferred regulation method

This allows self-regulation and improved homeostasis

During nappy changes utilise comfort holds or muslin wraps to upper body. Avoid supine positions and lifting legs up in the air during nappy changes, especially in extreme preterm babies. Nappy changes should ideally be performed in the side-lying position.

This allows self-regulation and improved homeostasis.

Lacking containment and lifting legs up during nappy changes causes distress. There is an increased risk of Intra Ventricular Haemhorrage (IVH) as this increases blood flow to the head and this increased cranial pressure can damage more fragile vessels.

Promote skin to skin wherever appropriate

Skin to skin promotes comfort and self-regulation, increases neurodevelopment,  decreases stress, reduces pain responses, stabilises respirations and physiological observations, improves bonding, increases breast milk supply, improves weight gain and leads to earlier discharge

Consider skin to skin or breastfeeding during smaller procedures

Due to evidence above it can be less distressing for the baby for heel pricks, blood sampling etc. to be performed during skin to skin as comfort and positive touch is already being promoted

Utilise parents or if inappropriate or they are unavailable, ask colleagues to assist with any procedure. Whenever possible, a two person approach is preferable as one can comfort, promoting positive touch, and one can carry out the procedure

Minimises disruption and allows a quick return to a stable condition as comfort is promoted throughout. Additionally the “comforter” will provide constant observation and therefore increased responsiveness to the baby. It is beneficial for both parents and baby to be together whenever possible.

Use muslins to wrap the baby during transfers e.g. for moving to them onto the scales, into the bath, between incubator and parent for skin to skin etc. As far as possible transfer baby in a tucked, side lying position and allow opportunities for foot bracing on the carrier, end of bath etc, the carrier should hold them close to the body

Wrapped transfers allow for the baby to more easily self-regulate and keeps them warm and calm.

Side lying and foot bracing reduce distress and provide comfort to support self-regulation.

When lifting or turning baby, move the head first then body, avoid swift movements through space, or brisk rotations. Keep the body in contact with surfaces as much as possible,

Support head

Movement in NNU is often sudden and unpredictable or static whereas the brain is expecting free fluid movement . The vestibular system is easily overloaded and this can be stressful for the baby

Head support will avoid the initiation of the moro reflex

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3.2 Positioning

3.2.1 Background:

In utero, babies are suspended in a warm, fluid environment where they are sufficiently supported and protected to allow effective growth and development. Conversely, the NNU environment can be harsh and unsupportive with no boundaries where the baby is nursed on flat hard surfaces. In the absence of buoyant amniotic fluid, neonates are also subjected to gravity. This is problematic in preterm infants as they have poor muscle tone and are unable to maintain a normal fetal position when placed on flat surfaces.

Risks of an inappropriate environment include:2-6,8,9,13-16

There are positives and negatives to all positions as no position is perfect for a prolonged period of time, so it is important to regularly change positions. Individualisation of each baby’s needs is vital to optimise the most appropriate position for them based on age, medical condition, respiratory needs, intravenous lines, and to meet their individual preferences.

For babies requiring ventilation, no position has been shown to be better for optimal ventilation. There is no clear guidance on how frequently a baby’s position should be changed so thorough inspection of skin and regular assessment of the baby’s comfort should guide position changing. When moving babies between positions, maintain contact at all times and do so slowly, in stages, not a quick flipping motion.

Babies can be over stimulated when objects are too close to their faces e.g. toys, mobiles, mirrors, ipads. These should be limited and not in constant sight to avoid over stimulation.

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3.2.2 Principles/Aim:

  • To create an environment which mimics that of in utero and promotes neuro-development, especially that of the motor and vestibular systems
  • Principles of alignment, comfort, support and flexion should always be followed
  • Utilise resources available including positioning aids, nests, rolls, boundaries to optimise positions
  • Be led by the baby’s cues – if they appear uncomfortable or unsettled consider readjusting position and offering comfort

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3.2.3 Method and Rationale




Nursed on the back with head either midline or to either side and hips and shoulders supported.

  • Suitable for all ages but <36weeks will need boundaries to support them
  • Especially useful for ventilated babies, those with Umbilical artery catheters (UAC), abdominal wounds
  • Recommended position for babies near term or those ready for discharge
  • Babies without monitoring or just on an apnoea alarm


  • A varied position (important to regularly change position)
  • Maximises access and observation
  • Safe sleep position for discharge


  • Increases heat loss
  • More difficult to breathe and digest
  • Harder to self-regulate
  • Uses more energy
  • Decreases sleep
  • Increases exposure to light


Nursed on front with limbs tucked under the body and head to either side.

  • Suitable for babies <36weeks, not when getting ready for home
  • Can be utilised in ventilated babies but head position must be closely monitored
  • Ideal for babies suffering from Gastro-oesophageal reflux disease (GORD) and following step down in respiratory support, e.g. extubated onto Continuous Positive Airway Pressure (CPAP)/High Flow


  • Can improve respiratory function and oxygenation
  • Promotes sleep and decreases energy use and heat loss
  • Helps digestion
  • Reduces crying and startle behaviour


  • Can prevent self-regulation and limits ability to adjust position independently
  • Can cause flattened posture, head moulding and shortening of muscles
  • Can be difficult and cause stress when turning out of this position


Nursed on either side with back and head supported to allow hands and feet to come together.

  • Appropriate position for most babies
  • When lying on the left, symptoms of GORD can be reduced


  • Supports flexed position
  • Allows self-adjustment of position and promotes self-regulation as in midline
  • Less likely to cause muscle shortening
  • Aids digestion, especially when on left side


  • Access to baby reduced, makes certain procedures more difficult
  • Sometimes requires support to optimise neck position which can impact on breathing and digestion


  • Preterm babies lack muscle tone to sit safely but older babies, e.g. those in surgical new-borns or who are long standing post-term infants may benefit from time spent in a chair which is appropriately supportive for the baby’s age and condition.
  • The midline position should still be aimed for so blankets or rolls should be used to support this.
  • Term or post term babies need interaction and stimulation for their development
  • Cues should still be followed and responded to, to prevent over stimulation
  • Inappropriate positioning or slouching/slumping in a chair can impact upon respiratory function and stability


  • It is vital that parents understand that although different positions and using boundaries may be appropriate in hospital, only sleeping supine is recommended at home.
  • To encourage this, boundaries must be removed and nursing babies prone must be stopped as babies near term and prepare for discharge
  • When preparing for discharge Sudden Infant Death Syndrome (SIDS) advice must be followed.
  • There is an increased risk of death through suffocation when babies at home sleep on their fronts and have excessive bedding in the cot with them

Nests and boundaries

How to make a nest…


Fold a towel diagonally to make a triangle and do the same with a sheet to cover it (it may have two triangles depending on the size of thetowel/sheet).


Starting with the longest end of the triangle make flat wide folds until you have a long roll.


Put the roll on it’s side and form into an oval shape, overlapping the small ends to make a rim near the head end. This can be opened at any time for easy access to the baby.


Line the oval with a muslin or soft cloth to secure the shape of the nest.


Place the baby inside the nest and readjust to optimise position. Smaller rolled muslins can be used to fill gaps and support the hips or back

Images: Foundation Toolkit for Family Centred Developmental Care, p50 I Warren, C Bond and W Bond, 2015.

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3.3 Light


3.3.1 Background

Artificial and natural light both have a role to play in the NNU environment; it affects the infant's physiology and development. It regulates the circadian rhythms of the neonate. It also supports the visual function of staff working within the NNU.

In utero some light reaches the fetus towards the end of pregnancy, this light is reddish long-wave light contrasting significantly with the high-density, bright light of the neonatal unit. During an infant’s admission to NNU they can be subjected to long periods of bright light exposure. Several concerns are raised in regards to this exposure:

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3.3.2 Principles/Aim:

  • To promote an optimal extra uterine development
  • Protect eyes from retinal damage
  • Reduce stress and protect infants neurodevelopment.

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3.3.3 Methods and Rationale



Maintain lighting levels at around 200-300 lux in the nursery. Lighting should be adequate to monitor infants safely.

Moonlight 5 lux - Sunlight at midday 11,000 lux

Neonatal nurseries: around 400- 1000 lux

Phototherapy 2400-3000 lux

Preterm baby’s eyelids are thin and allow considerable amounts of light to penetrate even when eyes are closed.

Reflexes in the preterm infant are absent/ reduced, therefore the retina cannot regulate the incoming light by constricting or dilating the pupil of the eye. These begin to develop from 32-34 weeks gestation.

Lighting needs to be flexible to accommodate needs of the baby and caregiver. Many activities can be carried out in moderate lighting (100-300 lux).

It is essential that there is adequate lighting to safely observe the infant and deliver care effectively, but balanced with the need to protect sleep, reduce stress and protect neurodevelopment of the infant..

Incubator covers should be used for all preterm, sick or neurologically compromised babies.

Ensure infant can be observed appropriately by lifting corner flap of incubator cover.

From around 32-34 weeks gestation carers need to begin increasing light exposure, whilst still shielding infant from direct bright overhead lights.

To provide the preterm baby with reduced lighting levels with the aim of promoting physiologic stability and reduced motor activity.

Infants who are developmentally ready are more likely to open their eyes and interact with parents/ carers. The gradual increase of light exposure will aid the development of circadian rhythms.

Babies nursed in open cots require protection from bright light until nearing term (37-40 weeks)

Use of cot canopies can shade the infant from overhead light, allowing for improved sleep patterns.

Shield infant's eyes during medical procedures that require increased lighting levels (eye mask or carers hand).

To aid physiological stability during procedures.

Protect other babies in the nursery from phototherapy lights.

Place cover around phototherapy lights to reduce ambient light levels.

Eye mask must be worn at all times when receiving phototherapy.

Phototherapy is around 2400-3000 lux thereby increasing ambient light levels.


Infants, in adjacent cots, not receiving phototherapy will not be wearing a protective eye mask, but will be subjected to extra light levels.

Ensure babies undergoing ROP (Retinopathy of Prematurity) screening are protected from bright lights following their examination.

Eye drops cause dilatation of the pupil and can result in the baby being more sensitive to light for up to 18 hours.

Vision- avoid placing strongly contrasting images/ toys in infants direct field of view before reaching term.

Premature infants cannot focus well and this may cause physiological stress. No research to support the use before term.

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3.4 Sound

3.4.1 Background

The neonatal unit is frequently a very noisy environment, resulting from human interaction and use of multiple pieces of equipment. This increased noise level can cause distress, disturbed sleep patterns, have an effect on neurodevelopment and also has the potential to cause hearing damage to the babies in our care. It has also been shown that working in a noisy environment can affect the wellbeing of parents and staff too.

The World Health Organisation and The American Academy of Pediatrics recommends that noise levels do not exceed 40-45 dB in NNU and < 35 dB is desired for sleep. The reported threshold for cochlear damage in adults is 80 dB, the immature cochlear is more sensitive thereby affected by lower noise levels. Maintaining noise levels at 45 dB is associated with reduced risk of developing noise-induced adverse effects, these effects can result in short and long term issues for the infant. Short term effects include tachycardia, tachypnea and hypoxia. Long term effects include higher risk of developing mild hearing loss (Hearing impairment is diagnosed in 2% to 10% of preterm infants versus 0.1% of the general paediatric population), problems with intelligence development and periventricular hemorrhage, and leukomalacia.



Telephone ringing


Alarms (set at 70% volume)

70db at 1 meter distance

Closing incubator doors

100-135 db

Bubbling in ventilator tubing

62-87 db

Tapping incubator with fingers

80 db

Talking around bedside (normal speaking voice)

60 db

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3.4.2 Principles/ Aims

  • Aid optimal neurodevelopment of the neonate
  • Provide a stress free comfortable environment.
  • Minimise potential long term negative impacts on the neonate and family.
  • Improved working environment for staff.

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3.4.3 Methods and Rationale



Education of staff and parents in regards to effects of sound and need for quiet.

Increased education will highlight to staff importance of quiet environment for the neonate in regards to neurodevelopment, growth and sleep disturbance.

Enable parents to gain a deeper understanding of their infant's developmental needs and gain empowerment.

Regular audit of noise levels in NNU at different times of day (ward rounds, hand over). Provide feedback to staff and parents.

Improve staff awareness of events which increase noise levels. Information sharing will enable team discussion for noise reduction strategies.

‘Quiet ward rounds’ only one speaker at a time during ward rounds.

Background conversations to be kept to a minimum.

Reduction in noise level around the infant.

Better communication between multidisciplinary team, with an aimed reduction in errors.

Improved parent/ carer satisfaction as all discussion points can be heard during ward round.

Non-essential conversations to be conducted away from infants bed space.

Hushed voices to be used in clinical area.

Noise disrupts sleep patterns for babies.

Hearing parent’s voices is thought to comforting to infants. This can be difficult to make out when there are other voices nearby.

  • Alarms to be keep on lowest sound level setting which is clinically safe.
  • Staff to respond to alarms as quickly as possible.
  • Telephone ringtones to be kept to a minimum and ideally to be kept outside clinical area.
  • Keep ventilator/ CPAP tubing free from water.
  • Close incubator doors gently
  • Do not place equipment on top of incubators.
  • Open packaging outside incubator.
  • Use of soft closing waste/ laundry bins in clinical areas.
  • Chair/ equipment not to be dragged across floor.
  • To aid in reducing noise levels around the infant.
  • Sudden noises can startle infants and cause physiological instability.
  • Noise disrupts sleep patterns, which affects growth and development.
  • High noise levels can be stressful for Infants, parents and staff.
  • A reduction in errors and improved performance in staff is associated with quieter working environments.

Use incubator covers.

Ensure infant can be observed appropriately while in use.

Aids in reducing noise levels reaching infant. Help to maintain a calm environment for the infant.

Encourage parents to talk softly to their baby.

Voice and language recognition indicate that auditory learning takes place before birth when the mother’s voice is the predominant stimulus.

The NNU should be a quiet calm environment the majority of the time (Noise levels will increased during emergency situations, but alarms and other non essential noise should be attended to where possible).

Infants should only be disturbed when clinically necessary. This is not always possible due to clinical demands of individual babies.

There is debate over ‘quiet hours’ as this suggests that the infant only requires one hour a day of quiet time, but infants should have a minimum of at  least one period during the day when they are undisturbed in a low light level, quiet environment.

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3.5 Smell and Taste

3.5.1 Background

When babies are born prematurely most will have a fully developed sense of taste and smell, however stimuli they experience are very different to the uterine environment. This can cause autonomic imbalance and interfere with normal development. This includes unpleasant tastes such as oral medication, multiple exposure to disinfectants, hand soaps, gels and perfumes. When babies are tube fed on the unit their exposure to taste stimuli can be minimal or even non-existent.  This lack of oral stimulation can negatively affect a baby’s perception of oral experiences

Stimulation of the gustatory and olfactory senses can affect the development of other senses and has an influence on attachment. It is important to ensure the neonatal unit is as free as possible from negative sensory stimulation and opportunities made for appropriate smell and taste experiences.

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3.5.2 Principles/Aim

  • Maintain stability and homeostasis
  • Promote appropriate chemosensory experience
  • Promote normal sensory development
  • Support and educate parents in supporting normal development

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3.5.3 Methods and Rationale




 Encourage the use of ‘bonding squares’ with   both parents but mothers in particular.

Exposes the infant to parents odours. Infants may begin to recognise their parents familiar odour.

Enables the mother to be exposed to the infants odour whilst expressing to aid milk production.

Improved parent/ infant bonding. May provide a positive experience for parents knowing their infant if exposed to their odour.

  • Education on Noxious smells for staff and parents.
  • Cigarette smoke

Reduction in strong scented hand creams

  • Allow alcohol hand gel to fully dry before approaching baby.
  • Open alcohol wipes/antiseptic preparations away from the incubator and baby
  • Avoid wearing strong perfume or aftershave
  • Advise parents to avoid smoking or using strong washing detergents as this will mask their individual smell

Increase education for staff and parents will highlight the effects noxious smells has on the infant.

Reduction in exposure to noxious odour for infant.

Improved ability to smell/ identify parental odours.


Promote close contact with parents eg kangaroo care



Encourage sensitive mouth care with EBM (refer guideline)

Infants have demonstrated that they can discriminate between tastes from 26-28 weeks gestation as taste and smell receptors are thought to be functional.

To promote positive taste experiences for infant.

To avoid oral aversion and delayed oral feeding.

Carry out oral stimulation program with tiny tastes of EBM (refer guideline)

Liaise with Speech and Language as per guideline 

Helps babies, who have been unable to feed orally, experience different sensations in their mouth.  Promotes the skills needed for oral feeding and prevent increased sensitivity or gagging. 

If a baby has a nasogastric tube offer medication via this rather than orally

If medication has to be offered orally avoid contaminating the entire milk feed

Dip bottle teats in milk after sterilisation and prior to use

Reduction in exposure to noxious tastes for infant

Offer tiny tastes of EBM from a finger or a dummy during tube feeds


To promote positive oral tastes.

To promote association between oral experience and gastric sensation.

Suckling aids peristalsis and will promote more positive feeding experiences

Encourage early breastfeeding experiences, particularly during skin to skin contact

Use sucrose or EBM during invasive procedures (refer guideline)

Promote positive oral tastes for the infant.

Will help promote lactation

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3.6 Common distress and comfort Cues

Stress/Disengagement cues

indication of instability or pain and discomfort

Stop or pause intervention

Comfort/approach cues  

signs of self regulation, relaxation and comfort

Appropriate time to attempt intervention

 *if baby is asleep, do not disturb whenever possible*

Increased breathing or long pauses

Colour changes, e.g. mottled, pale, flushed, grey

Extremes in posture, limp or stiff



Saluting or waving

Extended arms and/or legs

Finger splaying

“Protective maneuvers” hands over face or fisting



Grimacing, wrinkled brow

Glazed look





Yawning or sighing

Tongue extension


Straining or opening bowels

Steady breathing

“Healthy” colour, e.g. pink

Flexed position, softly curled up

Good tone

Smooth movements

Hands together or clasped

Grasping or holding on

Feet together

Relaxed open face

Attentive open face




Stable digestion, not squirming or positing

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Record: 5788
Clinical condition:
Target patient group: babies on the Neonatal Unit (NNU) and Transitional Care
Target professional group(s): Allied Health Professionals
Secondary Care Doctors
Adapted from:

Evidence base

References  and Evidence levels:
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.


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