Letter From the Editors
Neonatal providers and nurses, in particular, have been strong advocates of individualized developmental care. Neonatal-focused journals such as Advances in Neonatal Care routinely publish literature about individualized developmental care. Research surrounding the content of interventions and how they are delivered and thus what constitutes developmentally appropriate care for an individual infant and his or her family continues to evolve. Since developmental care was first promoted by Dr Heidelise Als in the 1980s,1 a body of literature has emerged to support the observation of infant behavioral organization (infant cues) in response to the stress of the neonatal intensive care unit (NICU) environment that is used to guide caregiving to minimize infant stress and optimize infant outcomes. Therefore, the context of infant caregiving centers around the infant. The overall goal of individualized developmental care is to promote the short- and long-term health and development of high-risk infants including interventions that promote the well-being of an infant's family.2
While most individuals agree that individualized developmental care is infant directed and caregivers should modify the environmental context to minimize infant stress, implementation of individualized developmental care is hindered by the lack of empirical evidence to guide the implementation of “specific substantive interventions.” The use of multiple interventions in most empirical studies has impeded our ability to understand what and when specific interventions (eg, music) should be implemented to promote the best infant outcomes. When single-intervention research is available, the generalizability of the findings is limited by small sample sizes and variability in the delivery and content of the intervention (eg, recorded vs live music).3,4 In contrast, when specific data exist to implement an intervention (eg, noise-reduction initiatives), other barriers exist around nursery design, technology, and cost. The American Academy of Pediatrics established maximum noise levels for NICUs in 1997,5 yet 20 years later nurseries struggle to maintain appropriate noise levels. Many medical, nursing, and iatrogenic caregiving events occur in the chaotic environment of the NICU simultaneously, yet they are not in sync with each other. It could even be said that these caregiving events are antagonistic to each other, increasing stress for the infant and potentially the family.
While there is little disagreement about the importance of attending to infant cues in the delivery of care, there are times when caregiving is intrusive and cannot be delayed to minimize infant distress. (The central line catheter is needed for antibiotic delivery and repeated central line catheter placements are sometimes unavoidable.) Unfortunately, there also continues to be circumstances when we as providers use the “necessity to deliver care” as an excuse to overlook infant cues. (Three infants need to be fed at 9 AM, and the nurse decides the unit's cue-based feeding protocol just will not work today.) To continue to advance the discovery of new knowledge about individualized developmental care best practices, future work should investigate strategies to eliminate or minimize the barriers to implementation. Developmental interventions continue to be at the top of the list for those interventions that are “missed” when staffing is poor or there is not enough time to spend with a family to support appropriate breastfeeding or discharge planning.6
Future intervention development should be designed to be practically implemented and of low cost. Research should also evaluate whether specific developmental interventions have short- and long-term benefits, when the intervention should be implemented (eg, age) to maximize outcomes, and the cost savings associated with the intervention. These types of studies may be difficult to fund but are essential to advance knowledge in developmental care research; maximizing short- and long-term outcomes of these infants must be our greatest concern. Getting infants to the doors of the NICU cannot be enough; we must think beyond the doors since much of what happens in the NICU has the potential to have lifelong effects.7
Debra Brandon, PhD, RN, CCNS, FAAN
Coeditor; Advances in Neonatal Care
Jacqueline M. McGrath, PhD, RN, FNAP, FAAN
Coeditor; Advances in Neonatal Care
1. Als H. Towards a synactive theory of development: promise for the assessment and support of infant individuality. Infant Mental Health J. 1982;3(4):229–234.
2. Macho P. Individualized developmental care in the NICU: a concept analysis. Adv Neonatal Care. 2017;17(3):162–174.
3. Palazzi A, Nunes CC, Piccinini CA. Music therapy and musical stimulation in the context of prematurity: a narrative literature review from 2010 to 2015 [published online ahead of print May 25, 2017]. J Clin Nurs. doi:10.1111/jocn.13893.
4. O'Toole A, Francis K, Pugsley L. Does music positively impact preterm infant outcomes? Adv Neonatal Care. 2017;17(3):192–202. doi:10.1097/ANC.0000000000000394.
5. Noise: a hazard for the fetus and newborn. American Academy of Pediatrics. Committee on Environmental Health. Pediatrics. 1997;100(4):724–727.
6. Rochefort CM, Rathwell BA, Clarke SP. Rationing of nursing interventions and its association with nurse-reported outcomes in the neonatal intensive care unit: a cross-sectional survey. BMC Nurs. 2016;15:46, 1–8. doi:10.1186/s12912-016-0169-z.
7. D'Agata A, Sanders M, Grasso DJ. Unpacking the burden of care for infants in the NICU. Infant Ment Health J. 2017;38(2): 306–317. doi: 10.1002/imhj.21636.