Programs that Work
Newborn Individualized Developmental Care and Assessment Program (NIDCAP)
Healthy and Safe Children
Children Ready for School
Children ages 0 to 5 exhibiting age-appropriate mental and physical development
Babies born weighing more than 5.5 pounds and improving outcomes for low birth weight babies
Children experiencing good physical health
Age of Child
Early Childhood (0-8)
Type of Setting
Health Care Provider
Type of Service
Health Care Services
Type of Outcome Addressed
Cognitive Development / School Performance
Evidence Level (What does this mean?)
The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) offers an individualized and nurturing approach to the care of infants in neonatal intensive care unit (NICU) and special care nurseries (SCN). It is a relationship-based, family-centered approach that promotes the idea that infants and their families are collaborators in developing an individualized program of support to maximize physical, mental, and emotional growth and health and to improve long-term outcomes for preterm and high medical risk newborns.
The therapeutic framework and method of NIDCAP provides early developmental support and preventive intervention, beginning immediately with birth. Numerous premature infants are born during or before the last trimester of gestation (beginning around 24 weeks), which is an exceedingly critical period for brain development. The infant's sensory experience in the environment of the NICU and SCN, including exposure to bright lights, high sound levels, frequent stressful and painful interventions, and diminished positive experiences, presents unexpected challenges to the immature brain during this sensitive period.
The goal of the NIDCAP approach is to minimize the mismatch between the immature brain's expectations and the overstimulating environment. In turn, NIDCAP seeks to improve brain development and long-term outcomes. The NIDCAP approach uses methods of detailed documentation of an infant's ongoing communication to teach parents and caregivers skills in observing an individual infant's behavioral signals. These sometimes subtle signals provide the basis for interpreting what the infant is trying to communicate and can be used to guide parents and caregivers to adapt all interaction and care to be supportive of the infant's behavior. Suggestions for care are made in support of the infant's self-regulation, calmness, well-being, and strengths and the infant's sense of competence and effectiveness. Such suggestions begin with support, nurturance, and respect for the infant's parents and family, who are the primary co-regulators of the infant's development; and the suggestions extend to the atmosphere and ambiance of nursery space, the organization and layout of the infant's care space, and the structuring and delivery of specific medical and nursing care procedures and specialty care. These practices ensure that a developmental perspective and an infant's environment are incorporated into the infant's care (see Als, 1995).
Infants and their families at risk due to premature delivery, low birth weight, and/or requiring care in a NICU and SCN for various risk reasons.
Many studies have evaluated NIDCAP. Resnick et al. (1987) studied 255 low-birth-weight babies (124 in a treatment group and 131 in a control group) and assessed them using the Bayley Scales of Infant Development in a blind evaluation. Becker et al. (1991) tracked the developmental and medical outcomes for preterm infants by looking at 21 infants prior to staff training and 24 infants after staff training. Als et al. (1994) investigated the medical and neurodevelopmental effects of NIDCAP on very low-birth-weight infants, and the randomly assigned treatment and control groups were followed up at eight years of age by McAnulty et al. (2009). Fleisher et al. (1995) randomly assigned 40 very low-birth-weight preterm infants (weighing less than 1250 g) who required mechanical assistance in breathing (ventilation) to one group that received NIDCAP or one that did not, and then they compared the developmental results for the two groups. Buehler et al. (1995) tested the program on a randomly assigned sample of 24 medically healthy preterm infants at low risk and compared them with a group of 12 healthy, full-term infants. Als et al. (2003) randomly assigned 92 very low-birth-weight preterm infants, weighing less than 1250 g and aged less than 28 weeks, to treatment and control groups. Als et al. (2004) randomly assigned 30 low-risk preterm infants to treatment and control groups in Boston, Mass., and conducted tests using magnetic resonance imaging to determine whether brain structures changed as a result of treatment.
Kleberg et al. (2008) examined the effects of NIDCAP on 68 infants' behavioral and pain responses to painful and stressful eye examinations following premature delivery by randomly assigning infants to a treatment group that received NIDCAP treatment and then the subsequent eye examination. Van der Pal et al. (2008) conducted a randomized trial of Dutch preterm infants, examining the effect of NIDCAP on parent reports of health-related quality of life. Finally, Maguire et al. (2009) examined the effects of NIDCAP at one and two years corrected age by randomly assigning 148 infants born at less than 32 weeks to treatment and control groups. (Corrected age is the age the child would be if the pregnancy had gone to full term.)
Key Evaluation Findings
Physical and health outcomes:
- Infants in NIDCAP had shorter stays on respirators, supplemental oxygen, and feeding tubes (Becker et al., 1991; Als et al., 1994).
- NIDCAP babies started oral feeding sooner and had better average daily weight gains, shorter hospital stays, and improved overall behavioral functioning (Fleisher et al., 1995; Als et al., 1994).
- NIDCAP babies showed reduced need for the following: tube feeding (23 days for babies given treatment versus 37 days for babies not given treatment), positive airway pressure (38 days for the treatment group versus 60 days for the nontreatment group) and length of hospitalization (92 days versus 115 days) (Fleisher et al., 1995).
- Hospital costs were dramatically lower for infants in the NIDCAP group (an average of $362,000 versus $491,000 for the non-NIDCAP infants) (Fleisher et al., 1995).
- In a sample of very low-birth-weight preterm infants, NIDCAP participants had a shorter duration of intravenous feeding, a shorter duration of transition to full oral feeding, and shorter durations of intensive care and hospitalization; a lower incidence of necrotizing enterocolitis (a medical condition that primarily occurs in premature infants in which portions of the bowels undergo tissue death); reduced discharge ages and hospital charges; and improved weight, length, and head circumferences (Als et al., 2003).
- Infant pain profiles during eye examination were not different between the NIDCAP treatment and control groups in Kleberg et al. (2008).
- A study of infants born preterm (less than 32 weeks) found no improvement in neurological outcomes at one or two years (corrected age) (Maguire et al., 2009).
- Regarding a sample of preterm Dutch infants at one year of age, van der Pal et al. (2008) found no improvements in health-related quality of life as reported by parents among those infants who participated in NIDCAP compared with those in a control group.
- The NIDCAP babies had a significantly lower incidence of developmental delay and scored significantly higher than the control group on mean mental and physical indexes at 12 and 24 months of corrected age (Resnick et al., 1987).
- Infants in NIDCAP had improved behavioral organization at two weeks corrected age and at nine months (Becker et al., 1991).
- In a sample of very low-birth-weight preterm infants, NIDCAP participants had enhanced autonomic, motor, state, attention, and self-regulatory functioning following the intervention compared with the control group (Als et al., 2003).
- A preterm NIDCAP group had better outcomes than a group of preterm non-NIDCAP infants in terms of behavioral performance and in the amount of activity found in the frontal lobe of the brain (Beuhler, 1995). This was also true among low-risk infants (Als et al., 2004).
- NIDCAP program participants had improved behavior scores during a painful eye examination compared with control group participants (Kleberg et al., 2008).
- A study of infants born preterm (less than 32 weeks) found no improvement in mental or psychomotor outcomes at one or two years of corrected age (Maguire et al., 2009).
- A follow-up study of NIDCAP infants at eight years old found significantly better right hemisphere and frontal lobe function in the experimental group than in the control group (McAnulty et al., 2009).
Neonatal intensive care nurseries, special care nurseries, chronic infant care facilities, and lead agencies for special-education services (for example, departments of education or departments of health), lead agencies for the quality of neonatal care implementation (for example, the American Academy of Pediatrics and the Joint Commission on the Accreditation of Hospitals), and others.
Federal Special Education funds (Part C of the Individuals with Disabilities Education Act) and state departments of health; private funds or endowments accessed through hospitals.
- All materials emphasize consistent caregiving by a primary team designated for each infant when the infant arrives in the NICU; all infants were observed before any hands-on interaction by the caregiver.
- Equipment is arranged aesthetically and in close proximity to ensure ready access to the infant at all times. Comfortable chairs are provided for parents' extended naps and overnight stays, and families are encouraged to personalize and decorate their infant's bed space with personal items (incubator cover, photos, stuffed animals).
- A peaceful and quiet care area is maintained for the infant—e.g., the infant is spoken to with a soft voice at all times, and NICU staff wear quiet shoes.
- Darkness is assured for the infant during sleep and low, muted light levels are maintained at all other times in order to support alertness. All light that falls on the infant's face is indirect.
- In timing caregiving, the infant's sleep-wake cycle alertness, medical needs, and feeding ability are considered.
- Trained developmental specialists are made aware of both infant and family development, and they support the primary care team. These specialists are full-time staff members.
- The infant is consistently supported and facilitated physiologically in well-aligned positions whether on the back, tummy, or side. Blankets, nesting, and swaddling help assure proper positioning. Supports were used to increase and build on the infant's ability to support him or herself, and the use of supports diminished as stability increased.
- The parents are supported from the beginning of the feeding process in their role as the infant's most important nurturer and provider of nutrition. Feedings are timed to be supportive of the infant's sleep-wake cycles so that the infant may learn to recognize feelings of hunger and satiation. Parents are supported to breastfeed.
In observing the infants, NIDCAP developmental specialists focus on the "stability" and/or "stress" signals communicated by the infant in relation to the following:
- Autonomic nervous system (signals related to breathing, heart rate, skin color, or body temperature or if the infant experiences tremors or is easily startled)
- Motor system (signals related to muscle tone, posture, and movement patterns)
- "State" organization system (signals such as robustness, sleep patterns, alertness, or crying)
- Attention/interaction system (processing and responding to the environment)
- Self-regulatory system (balancing of the various systems).
These observations are used to develop and implement a plan for each infant that addresses issues such as lighting, noise levels, positioning, touch, and timing of interventions.
The specific NIDCAP system is proprietary but involves intensive and structured training of staff. Staff determine an appropriate method of interacting with each family on a case by case basis.
NIDCAP designates a primary care team for each infant within hours of the infant's arrival in the NICU. This team includes a developmental specialist, social worker, respiratory specialist, nurse, physician, and key family members. Some hospitals also have a developmental-care nurse/educator, other health care specialists, and/or parent representatives. Intensive training is needed to become a NIDCAP developmental specialist.
The process of starting a NIDCAP center usually takes about five years and can involve up to 15 people at a site. The required training costs vary depending on training location. The costs are approximately $1,500 per day for each trainee, plus expenses, if the training is done on site.
Issues to Consider
This program received a "proven" rating. Several controlled experiments, including two with reasonable sample sizes (40 very low-birth-weight babies in one group and 255 low-birth-weight babies in another), have shown the program to be effective at improving outcomes for low- and very low-birth-weight babies. The program has been shown to be effective in various sites throughout the country, and several studies indicated that low- and very low-birth-weight babies who participated in NIDCAP showed gains similar to those of full-term babies.
Not all of these improvements have, however, been shown to persist beyond the first months of life. Several studies examining outcomes at one year of age and beyond found no significant effect of the program, and critics have cited this as a reason to question the effectiveness of the program (Jacobs, Sokol, and Ohlsson, 2002). A meta-analysis of the NIDCAP randomized controlled trials published to date concluded that there was not as yet sufficient evidence to broadly recommend NIDCAP as a standard of clinical care, stating that not only did the randomized controlled trials all involve small sample sizes, but moreover they lacked follow-up into school age (Jacobs, Sokol, and Ohlsson, 2002).
Boston Children's Hospital, Colorado Consortium of Intensive Care Nurseries, Phoenix Children's Hospital, St. Vincent Hospitals (Indiana)
National NIDCAP Training Center
Enders Pediatric Research Laboratories
Children's Hospital Boston
320 Longwood Avenue
Boston, Mass. 02115
www.nidcap.org (Web site)
Resources include a NIDCAP Program Guide and training through NIDCAP training centers across the United States. Contact Boston Children's Hospital for ordering information at the address above or the NIDCAP Web site.
Manual for the Naturalistic Observation of the Newborn (Preterm and Fullterm),
Boston, Mass.: Children's Hospital, 3rd revision, 1981, rev. 1995.
Als, H., Program Guide—Newborn Individualized Developmental Care and Assessment Program (NIDCAP): An Education and Training Program for Health Care Professionals, Boston, Mass.: Children's Medical Center Corporation, 11th revision, 1986, rev. 2008.
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