The in-utero early sensory
experiences of the fetus are essential for
normal brain development during the perinatal
period. The premature infant (considered as
extra-uterine fetus) is deprived of in-utero
sensory experiences, rather exposed to unusual
sensory stimuli in the Neonatal Intensive Care
Units (NICU) that pose risk to the developing
brain in terms of adverse neuro-developmental
outcomes . Developmental care interventions
(DCI) is an umbrella term comprising of several
interventions aiming to facilitate the infant
cope with the environmental demands and also to
modulate the sensory experiences as a result of
its early exposure to the same. The expected
outcome of DCI is improvement in overall
physical, cognitive, social and emotional
development of the new born. The reviews on DCI
to high risk infants indicate that there are
controversies in the type, mode and timing of
stimuli presented, given the complex nature and
heterogeneity of interventions. Some even argue
that the very purpose of DCI can be detrimental
to the growth and development of high-risk
infant if not delivered properly. Till date the
evidence on the effectiveness of these
interventions is inconclusive [2,3].
We herein provide the recent
updates on developmental care interventions of
preterm very low birth weight infants, its
clinical importance and available best evidence.
The role of mother and the family for the
success of DCI program will also be appraised.
Typically DCI interventions
involve presentation of multi-modal sensory
experiences and modifications of NICU
environment. Such interventions are more often
extended beyond the NICU stay of the neonates
and are carried out throughout the infancy.
However for the convenience of review, the
developmental interventions are discussed under
the major sensory modality with which the
preterm infants are stimulated.
The fetus during the prenatal
period receives rich tactile sensory experiences
as it is bathed by the amniotic fluid. During
NICU stay the preterm infants are deprived of
constant tactile stimulus of amniotic fluid and
are also exposed to varying touch stimulus
(other than the mother) on handling during
routine medical and nursing procedures. Several
studies have made consistent observations on
adverse effects of such handling procedures that
include hypoxia, bradycardia, sleep disruptions,
increased intracranial pressure and behavioral
agitation. Thus supplemental tactile stimulation
is indicated at the same time ensuring minimal
and gentle handling .
During the non-contact period
of the infant and the mother in NICU, the
preterm infant is deprived of the tactile
stimulus. This can be overcome by swaddling that
involves wrapping the infant with sheets of
cloth or blanket and is done prior to
positioning on cradle board. This method is also
referred to as tucking, containment, binding or
bundling. The systematic review on swaddling
reports that swaddled infants have longer sleep
and are less aroused; have improvements in
physiological (lower heart rate) and behavioral
states (calms infants, induces and prolongs
sleep, fewer startles); alleviates pain and
prevents hypothermia. The study also reported
improved neuromuscular development and motor
organization following swaddling . Negative
effects of swaddling include respiratory
infections because of tightened swaddling;
increased risk of sudden infant death syndrome
(SIDS) when swaddling is combined with prone
positioning and increased risk of hip dysplasia
as the hip is maintained in extension and
adduction in swaddled position. It also
increased risk of hyperthermia when misapplied
and decreased postnatal weight gain because of
early separation from mother, longer sleep, less
nursing requirement and delayed breast feeding
Gentle Human Touch and
Infant massage therapy
involves gentle touch, stroking or rubbing the
infant with hand using light/moderate pressure.
Gentle Human Touch (GHT) approach involves
placing one hand over the infant’s head and
other over the lower back extending to the
buttock for 10-20 minutes. A study on GHT
reported that this type of touch has no adverse
effects on mean heart rate or oxygen saturation
levels; however, such touch resulted in
increased respiratory regularity, improved sleep
cycles (decreased active sleep and increased
quiet sleep), motor activity and behavioral
distress during periods of gentle touch . A
modification called Touching and Caressing -
Tender in Care (TAC-TIC) therapy has been
reported that enhances mental development,
improve physiological states and behavioral
reactions, improve sucking behavior and
cognitive performance within the neonatal period
Several studies have reported
the potential benefits of massage with or
without kinesthetic stimulation . The
systematic review on massage reported improved
weight gain, improved physiological and
behavioral states, decreased stress behaviors,
improved pain alleviation, reduced postnatal
complications, shorter hospital stay and
improved performance in developmental scores;
however it lacked strong evidence . Some
studies have shown that the massage benefits are
more pronounced when massage is combined with
usage of specific oils 
Sleep cycles and awake/alert
states of the newborn are essential for optimal
neuro-developmental outcomes. The medical and
nursing procedure on preterm infants elicits
pain and disturbs the sleep-awake cycle that
would result in adverse neuro-developmental
outcome and hence there is a need to alleviate
pain . A systematic review that included 51
randomized controlled trials reported sufficient
evidence to recommend kangaroo care,
non-nutritive sucking, and swaddling/facilitated
tucking interventions, rocking/holding for
reduction in both pain reactivity and immediate
pain-related regulation that influences positive
neurobehavioral states . Bellieni, et al.
 used sensorial saturation, a multi
sensorial stimulation technique consisting of
tactile, vestibular, gustative, olfactory,
auditory and visual stimuli, as a means of
analgesic tool for heel prick in preterm
The infants should be swaddled during
the non-contact period with the mother
and while sleeping; adverse tactile
stimulation needs to be avoided during
sleep cycles. Gentle touch, massage and
kangaroo mother care (KMC) should be
provided while the infant is alert and
Range of motion activities:
The spontaneous movements of extremities are
very much decreased in preterm very low
birthweight infants because of hypotonia.
Further, with swaddling and minimum handling
requirement of infants in NICU, they are further
deprived of physical activity. Moyer-Mileur,
et al.  reported positive effects of
range of motion activities and gentle
longitudinal compression of extremities (passive
weight bearing) on improved weight gain, bone
width and bone mineral density. Similar
observations were reported with evidence of
increased circulating Leptin levels correlated
with birth weight suggesting increased bone
mineralization . A systematic review concurs
that there is some evidence that physical
activity programs might promote short-term
weight gain and bone mineralization in preterm
infants but lacks evidence for long-term
effects. The literatures in systematic review
lacked methodological and reporting quality
The preterm infants have hypotonia that
brings about difficulty in using the extremities
in midline and sustaining the symmetrical
flexion posture and movements. During NICU stay,
such infants should be positioned in supine (in
swaddled position) during sleep cycles; also in
prone position for brief period when the infant
is alert and awake. Infants positioned in prone
are reported to have attained motor milestones
much earlier than infants positioned in supine
position. Prone positioning may also prevent
positional deformational plagiocephaly, which
may have some implications on neurodevelopmental
behavior [18,19]. A transient delay in motor
development has been reported for healthy term
and low-risk preterm infants who were not
exposed to the prone position or who did not use
infant equipment . Infants positioned in
supine, prone and side-lying maintained in
tucked flexion respond with more spontaneous
midline activities and symmetrical antigravity
flexion postures, similar to that of full term
The range of motion
activities should be combined with
massage for improved weight gain. The
infant should be positioned supine while
sleeping; and in prone / side-lying
while alert and awake for improved neuro-motor
Olfactory - Gustatory
The amniotic fluid that is
being swallowed by the fetus facilitates early
chemosensory experiences. During postnatal
period these chemosensory experiences combined
with sucking reflex activity facilitate
nutrition seeking behavior and also the tactile
needs of the infants (to feel relaxed and
secured with the mother or to explore the
environment around it). Preterm infants are not
able to coordinate sucking, swallowing and
breathing and hence will depend upon alternative
feeding methods viz. tube feeding, cup
feeding, syringe or dropper feeding, bottle
feeding with expressed breast milk. These
feeding methods deprive the preterm infant from
normal sensory experiences of taste and smell.
Further, the unpleasant and noxious odors
arising from the hospital disinfectants,
solutions, and antibacterial compounds can have
a negative impact on already deprived smell and
taste sensations. The extended duration of
alternative feeding methods also has a negative
impact on the sucking behavior of these preterm
Non-nutritive sucking (NNS):
Non-nutritive sucking involves sucking of the
pacifier (physiologically designed nipples), the
digit or the emptied breast. During gavage
feedings and transition from gavage to
breastfeeding, non-nutritive sucking should be
encouraged as part of developmental care
interventions. It facilitates the sucking
behavior of infants and will also improve
digestion of enteral feeds through secretion of
specific digestive enzymes mediated by vagal
innervations of oral mucosa . A systematic
review on the effect of non-nutritive suckling
reports significant decrease in the length of
hospital stay and no clinically significant
changes in weight gain, energy intake, heart
rate, oxygen saturation, intestinal transit
time, age at full oral feeds and behavioral
state . It also identified positive clinical
outcomes of NNS such as smooth transition from
tube to bottle feeds and better bottle feeding
performance. No negative outcomes were reported
in any of the studies .
Infants on longer duration of alternative
feeding methods have greater difficulty in
transition to breast feeding. A randomized
controlled trial on Premature Infant Oral Motor
Intervention (PIOMI) program reports improved
transition and increased feeding tolerance from
tube-feeding to breastfeeding and shorter
duration of hospital stay. The five minute
stimulation program involved assisted and
resisted movements of oro-facial muscles;
facilitated coordinated movement of cheeks,
lips, gums, tongue and palate, and digital
stroking of the same .
involves active sucking of the mother’s breast
by the infant. Human milk is the
preferredexclusive nutrition to improve weight
gain, immune status and cognitive development of
the infant . Breastfeeding allows maternal
involvement in feeding and maternal confidence;
facilitates mother-infant interaction, bonding
and attachment pivotal for socio-emotional
development of the infant. Exclusive breast
feeding is part of the standard kangaroo mother
care. The results of a systematic review
indicate that optimal duration for exclusive
breastfeeding should be at least six months and
prolonged breast feeding durations does not have
any beneficial effects on cognitive ability
. The results of two large independent
population based cohorts of very preterm infants
on breast feeding reports better neuro-developmental
outcomes despite sub-optimal weight gain .
feedings and transition from gavage to
breast feeding, non-nutritive sucking
should be combined with oro-motor
stimulation for smooth and early
transition to breastfeeding. Exclusive
breastfeeding should be continued at
least for six months.
Positive effects of
vestibular stimulation on arousal level, visual
exploratory behavior, motor development and
reflex integration have been reported in the
The fetal response to
auditory stimuli (maternal voice) indicated by
spontaneous movements is noted as early as 27
weeks of gestation that establishes social
attachment and communication during early
development. Exposure to noise levels of greater
intensities arising from various equipments in
the NICU environment act as stressors to the
preterm infants .Darcy, et al. 
in their descriptive study recommend behavioral
and structural changes to abate increased sound
levels in NICU. Behavioral changes involve staff
sensitization on recommended noise levels and
its impact on the infant; encouraging nurses to
silence alarms promptly, using quieter alarms or
lights, and encouraging conversation away from
the bedside can all help decrease the noise
level in a NICU. Structural changes to the NICU
physical environment would serve as the long
term strategy in noise abatement.
An expert review panel has
recommended the need for a system of regular
noise assessment, sound limit at 50 dB(A),
development and maintenance program of noise
control and abatement, improved parent-infant
interaction through parental voices at the
bedside, non-use of earphones and other devices
attached to the infant’s ears for sound
transmission or routine / unattended use of
recorded music or speech in the environment of
the high-risk infant . Similar findings have
also been reported from a recent Indian study
The visual system is the last
among all the sensory modality to develop and
the visual pathway matures only at the time of
birth around 39 to 40 weeks. Visual experience
for healthy visual development requires ambient
light (not direct light); and, after 2 to 3
months, color. Thus the visual care
interventions for preterm infants until 40 weeks
corrected age will include exposure to rhythmic
low level ambient lights for entrainment of
circadian rhythm, prevention of eyes from direct
light exposure, and facilitation of sleep cycles
Cycled lightings in NICU as
visual stimulation are used to establish
circadian rhythms of rest-activity cycles in
preterm infants. Infants who were exposed to
diurnally-cycled lighting while in intensive
care experienced both physical and behavioral
developmental benefits; improved weight gain,
early transition to oral feeding and shorter
hospital stay . A meta-analysis on cycled
lighting effects on preterm infants in NICU
reports a trend to improved weight gain, shorter
length of hospital stay and less incidence of
Retinopathy of Prematurity (ROP) when compared
to near darkness or continuous bright light
The preterm infants should only be
exposed to ambient and cycled lightings
and not to direct / continuous bright
light till 40 weeks corrected age.
Kangaroo Mother Care (KMC):
The standard kangaroo mother care includes
intermittent prolonged skin-to-skin contact of
the infant with the mother and exclusive breast
feeding. KMC provides tactile stimulation to the
infant by having prolonged skin-to-skin contact
with the mother; kinesthetic-proprioceptive
stimulation by swaddled positioning of the
infant; olfactory-gustatory stimulation by
breastfeeding; oro-motor stimulation by sucking
the nipple and auditory stimulation by the
maternal voice. Skin-to-skin contact improves
neurobehavioral organi-zation and physiological
states; prevents hypothermia in preterm infants
as these high risk infants have poor
thermoregulation. Further it improves
infant-mother interaction, bonding and
attachment essential for emotional and social
The clinical evidence of KMC
on physiological states describes clinically
acceptable and stable ranges of heart rate and
respiratory rate than the incubator period;
statistically significant increase in oxygen
saturation levels compared to incubator values;
significant reduction in desaturation levels as
a result of KMC compared with swaddled holding;
significant reduction in apnic spells when
compared with incubator care; increase in body
temperature and maintenance of thermal
regulation; decreased levels of cortisol;
statistically significant increase in weight
gain; decrease in the incidence of nosocomial
infections and improved blood glucose levels.
The clinical evidence on neurobehavioral
outcomes following KMC has shown improved sleep
patterns and organization; decreased crying
frequency; enhancement of breast feeding amongst
preterm infants; increased alertness/attention
and reduction in overall likelihood of
neurodevelopmental delay. The psychosocial
effects of KMC have shown to improve parental
feelings and interactions with the infant. Early
initiation of KMC, prolonged duration
(continuous and overall intermittent duration)
and frequent KMC intervention are reported to
have more beneficial effects [37,38].
Other models of multi-modal
sensory stimulation: White-Traut documented
the positive effect of Auditory, Tactile,
Vestibular and Visual (ATVV) intervention on
increased alertness, faster transition to
nipple-feeding, and decreased length of
hospitalization. . The study on RISS (Rice
Infant Sensory Stimulation) intervention, that
combines talking, massage, eye contact and
rocking, has reported to enhance mother-infant
interaction . Another intervention model,
comprising of home-based early stimulation
carried out by the mother has been reported to
improve the developmental status of at-risk
babies at 1 year .
multi-sensory stimulation nature of KMC,
it should be initiated at the earliest
and should be continued at least for six
months along with exclusive
The success of developmental
care interventions, in NICU and beyond hospital
stay, largely depends on the engagement of
infant’s mother and family in the intervention
program. The Literature on Developmental Care
Interventions mostly reports positive effects on
neurodevelopmental outcomes, physiological and
behavioral states. Since the components of
Developmental Care Interventions are
cost-effective and feasible, the interventions
should be carried out to help the preterm
infants cope with the environmental demands in
NICU and beyond hospital stay. The structuring
and designing of NICU environment for the high
risk neonatal graduates has important policy
implications for neonatal healthcare.
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