Observer

The Official Publication of the NIDCAP® Federation International

2022 | VOL 15 | NO. 1

Developmental“To be able to carry a child isa gift, giving birth in Sweden
is a privilege, to be cared foraccording to NIDCAP is beyond
everything.”—Magdalena Persson Pettersen
and André Persson

FAMILY VOICES

Connection
is essential.
— Jacques Sizun MD

INSIDE
Family Voices ................................................ 1
Editorial ............................................................ 4
Member Achievements .................... 5
Abstracts ......................................................... 6
Journal Club Presentations ........ 14
John Eugene Buehler, Jr. ................ 18
Trauma Informed .................................. 20
Developmentally
Supportive Care
Science Desk ............................................ 23
Reflections on the .............................. 25
NIDCAP Trainers Meeting
NIDCAP Training Centers .............. 28
Worldwide
Global Perspective-Ireland ........ 30
NIDCAP on the Web ............................ 32
NIDCAP Training Centers .............. 34
DOI: 10.14434/do.v15i1.33773

DOI: 10.14434/do.v15i1.33785

Magdalena Persson Pettersen and André Persson | Column Editor – Debra Paul, OTR/L

NIDCAP from a Parent’s PerspectiveIt was August 15th. Magdalena’s water
breaks and we travel at a high speed to thehospital. Early in the pregnancy we had
been told Magdalena could not sit, only lie
down. We are keeping positive thoughts. The
baby is healthy and is strong. Should we callbefore leaving for the hospital? Remember
the Vitamin K injection. We can do this! In achaos of thoughts, words, and exhortations between the contractions, we try to be brave andremind ourselves that “nothing has happened
before it happens”.

After a troublesome pregnancy, we are
finally here. The day when our boy decided to see the light of day. We arrive to thehospital. Like flies around a piece of sugar,
the hospital staff flocks around us and dotheir utmost to stop the contractions andskillfully manage to give us a break of afew hours. An obstetrician rushes into

the room to announce that a researchstudy on immediate skin to skin contact
directly after birth is being conducted at
the hospital and that we match the study
group, as we are now expecting the preterm
birth of our son. She gathers herself as if
she understood very well that this was notreally a good time for us to receive a lot of
new information. But because she says so,
we are attracted to next steps. We consider
the pros and cons and decide to take ourchance on the practice explained to us. The
doctor responsible for the study is called tothe hospital and a meticulous presentation
about the study and its risks versus benefits
is pointed out for us. There are no risks in
our heads. Just a win. Now the problem
remaining is that the chance to hold ourboy right from the start is decided in the
toss of a coin.
(continued on p. 2)

Family Voices, continued from p. 1

There is nothing natural about being
separated from your child.

The doctor’s obvious joy cannot be missed when she informs
us about the outcome of the draw. We will get to hold our son
from the very first second. We will not leave him.
A large weight falls from our shoulders and from this moment on, we are convinced that everything will go well.
The midwife looks in on us in the middle of the night justto see how we are. There were no contractions, and everything
was calm, and we agree on a quick check just to be sure. Theeyes of the midwife are wide-open as she throws herself at
lamp buttons and the alarm buttons and loudly and joyfully
shouts “we are giving birth here!” In an instant, the room isfilled with medical staff and machines. The birth comes inwhat we think can be called rocket speed. Benjamin arrives
into the world after nine minutes and lays on his mother’schest. He is a small wonder and is checked and connected todevices. He gets help to breathe. The focus and seriousness inthe eyes of healthcare professionals is unwavering. We observe
them all in detail. Their facial expressions and behavior reassure us. Dazed and dizzy, we rest in their safe hands. We lookat our beautiful baby boy and feel proud and calm.
After two hours we are transported to the neonatal ward.
We are all good. Our son is with us and still on his mother’schest and is healthy and strong. He just needs a little help toget on track, grow and develop. Just as the doctor informed
us about many weeks earlier when we were getting ourselves
ready for childbirth in week 25.
Anyone can have children. But it takes something
special to become a parent.

The IPISTOS (Immediate parent-infant skin-to-skin) study
that we were included in emphasized that skin-to-skin careshould be carried out for at least six hours to provide positiveeffects. We were both convinced that our little boy needed us
24/7 and divided the day into eight-hour shifts to be able togive the best care for him. We took turns having our little one
on our chest, skin to skin. The days went by, and seven days
passed before Benjamin was put in his bed.
With a firm and secure hand from the healthcare teamwe were surrounded by, we were guided through newborncare and parenthood. We learned how important it is to speak
in a lowered voice; how to provide positive touch and not to“stroke” Benjamin on his skin; how to protect him againstbright light; how to support him with soft hands, arms and ourbodies; how to provide safety and calm; how to feed and comfort him; how to wash him, care for him, and when that timecame, how to arrange his bed for best support. When placing
Benjamin in his own bed for the first time at seven days ofage, we got to learn about the importance of providing a
blanket with our scent for Benjamin to feel our presence. All
this was given to us allowing time for us to adjust and become2 • 2022 • Developmental Observer

Immediate skin-to-skin with Magdalena after Benjamin’s birth

comfortable caring for Benjamin. We got the best for our son
and with that we were shaped into secure and calm parents
who could focus on providing love and care to our son.
It was unclear whether Benjamin could be breastfed due
to a previous operation. But after a few days with Benjamin on
our chest, we were asked to try breastfeeding. It was a fantastic
feeling when Benjamin was put to Magdalena’s breast and withthe help of a small “taste portion” (breast milk in a syringe)
and with enormous willpower, Benjamin took the breast for
the first time. He who was so small. How could he know? How
could he cope? By alternating tube feeding and breastfeeding,
he got his meals.
Can you stay in the hospital forever?

The days and nights passed, and we were moved into a family
room. The breathing alarm went awry the first night and wewere scared for the first time. When we lived in the intensive
care unit, the staff kept an eye on the screens, and we kept an
eye on Benjamin. Now it was just us. Were we supposed tokeep an eye on him while sleeping? We do not know if it was“If there is a time in life when
you have to try your luck, it must
be when having a chance for“special treatment “ to get the best
opportunity to protect your child.”—Magdalena,
Benjamin’s motherexhaustion or a feeling of safety that made it possible for us tosleep, but the night passed, and we heard neither beeping nor
howling except those from our own alarm clock that rang at
Benjamin’s feeding time.
At rounds the next day it was announced that we would
have the opportunity to go home any day. Benjamin was strong
and healthy. But how could we leave the NICU? It was evident
that the doctor was used to parents’ concerns, and she reassured
us and conveyed security. She reminded us of everything we
had learned and that we were well prepared for taking Benjaminhome. We also got relevant CPR and first aid training and before
discharge and had a mandatory conversation with a counselor.
On August 31, after thorough checks, Benjamin was transferred to neonatal home care. We carefully positioned him in
the car seat, carried him out of the NICU and lifted him into
the car. The same car that almost one year earlier, we had toleave empty-handed after a previous pregnancy. Memories hit
us and fear was a fact. We took a few deep breaths, looked at
our son and brought out all the strength we had built up overthe last few weeks and off we went! The feelings we experienced at that moment cannot be described in words. We were
full of fear and were crying and laughing at the same time.
Benjamin was here with us, and he was fine. He curled up in
his car seat with his pacifier blanket next to him. He was newly
fed, calm, and relaxed, was breathing well and had a nice complexion - everything that is important. Let’s go home! Home tous – the three of us!
In the home care unit, we had a primary care nurse andshe visited us twice a week to check Benjamin’s weight andfood intake. She patiently answered millions of questions
from us. Benjamin grew as expected and made giant steps in
his development. After only a few days in home care, Benjamin chose to eat full meals with a bottle and even cuddled at
the breast afterwards. On September 11, Benjamin’s feedingtube came out with a sneeze. He was probably as fed up withthe tube as we were. We agreed that food should be enjoyedthrough the mouth and the tube was history.
When we were discharged from the hospital and the NICU
– what an indescribable feeling! At last, we were just like an ordinary family dealing with vomit, diapers, and visits to the healthcenter. One thing that we continued to do, however was to enjoy
our little boy skin to skin as soon as opportunities arose.

everyone. This makes us so sad. Never had we thought about
what newborn care could look like and does looks like formany premature babies. We have been asked if we were afraid
or worried about having a prematurely born child. Our only
fear now, when we know that other possibilities exist, is thatsomeone, somewhere will have to be cared for according to“routine” care in an extremely old-fashioned way and will haveto be separated from their little one.
Being able to care for your child skin to skin, when there
is a medical possibility, feels like such an obvious thing. To beable to care for your child skin to skin after a turbulent time
where the odds have swayed is indescribable. A small childneeds his parents, a tiny child needs them even more.
And if a parent’s love and closeness is not paramount in achild’s wellbeing, then what is?
Thank you everyone at The Astrid Lindgren’s Children’s
Hospital and everyone fighting for newborn and small babies
and their parents to be able to be together always!

“Give the children love and evenmore love and the common sense
will come by itself.”—Astrid Lindgren

Gratitude and sadness.

We are so grateful for getting the opportunity to be with ourson from the very start… to be able to be close to him all thetime, never to be separated, and to hold him skin-to-skin. We
also look back at all the help we got to become the best parents
for our boy. Only the stars know what life would be like if we
did not end up right there and then in this country, at this
hospital, and in the skin-to-skin study!
Now, two years after Benjamin’s birth, we understandthat we had a journey in newborn care that is not offered to

Benjamin was 2 years, 2 months corrected age in December!
He lives with his proud parents, Magdalena and André in
Stockholm, Sweden

2022 • Developmental Observer • 3

Editorial

DOI: 10.14434/do.v15i1.33774

T

his issue of the Developmental Observerlaunches the move from a newsletterto the official publication of the NIDCAP
Federation International. We have a fresh
look and have introduced some new ideas
as we increase to three issues each year
– February, June and October. With thisexpansion we would like to receive stories
and articles from the membership. You can submit in any language,
or work with the editorial team if English is not your first language.

We are challenged each year to meet virtually, yet the content
of the NIDCAP Trainers Meeting goes from strength tostrength. In this issue we see a global contribution from Japan,
Italy, Israel, Canada, Sweden, India, USA, Ireland, and France.
These perspectives, research and practices all support the
NIDCAP approach to care of the Newborn and their families.
The abstracts contribute to the body of evidence for NIDCAP,
and we have included the Journal Club summaries for the
first time.

Magdalena Persson Pettersen and André Persson from
Sweden share their beautiful story of Benjamin’s start in life withcouplet care and all the benefits of this sensitive approach inavoiding separation. We hear about Trauma Informed Care andthe road to self-discovery from Kristy Fuller and her team. Our
regular features take us to Ireland to learn about developmental
care and Jeff Alberts challenges us from the Science Desk.
It is always a pleasure to hear about the fantastic achievements from the membership and this issue we congratulate
Pierre Kuhn on his award. We also have a sad farewell to John
Buehler who was a strong supporter of the NFI over the years.

Kaye Spence AM

Senior Editor – Developmental Observer
Adjunct Associate Professor / Clinical Nurse Consultant
Australasian NIDCAP Training Centre / Sydney Children’s
Hospitals Network / Western Sydney University / Australia

Editorial Board
Jeffrey R. Alberts, PhD, is Professor of
Psychological and Brain Sciences at Indiana
University -- Bloomington (USA). Jeff is also a
NIDCAP Professional and blends his lab studies withsimilar research at Cincinnati Children’s Hospital
Medical Center.

gretchen Lawhon, PhD, is the Clinical Nurse
Scientist with Newborn special care associates, atAbington Jefferson Health and a NIDCAP Master
Trainer. gretchen has reviewed articles for peer
reviewed journals. gretchen has extensive experience
as a clinical nurse scientist and has authorednumerous articles in her areas of expertise.

Diane Ballweg, MSN, is the Developmental
Specialist at WakeMed Hospital in Raleigh, North
Carolina, USA. Diane’s writing and editing experience
also includes reviewing for several peer reviewed
journals and authoring several journal publications
and book chapters related to developmental care.

María López Maestro is a Neonatologist at the
Hospital 12 de Octubre in Madrid, and is a NIDCAP
Trainer and Member of the National Committee forthe implementation of Developmental Centered Carein Spain. Maria has 10 research works.
https://orcid.org/0000-0002-0545-6272.

Deborah Buehler, PhD, is a developmental
psychologist with expertise in developmental carewithin newborn and infant intensive care nurseries.
Her work has focused on NIDCAP research,education and mentorship, and awareness. Deborah
has authored and co-authored papers and manuals
pertaining to NIDCAP care.

Debra Paul is an occupational therapist and
NIDCAP Professional at Children’s Hospital Colorado
in Aurora, Colorado and the Column Editor for the
Family Voices section for the Developmental Observer.
Debra writes policies and guidelines which requires
succinct writing and an eye for editing.

Sandra Kosta, NFI Executive Director of
Administration and Finance, has been an Associate
Editor for the Developmental Observer since 2007.
As a Research Specialist at Boston Children’s
Hospital, Sandra has co-authored several papers
on the effectiveness and long-term outcomes of
NIDCAP Care.

Kaye Spence AM is a clinical nurse consultant andclinical researcher with numerous publications in peer
reviewed journals and several book chapters and is apeer reviewer for eight professional journals. She is apast Editor of Neonatal, Paediatric and Child HealthNursing. https://orcid.org/0000-0003-1241-9303

4 • 2022 • Developmental Observer

Member Achievements
Congratulations to Professor Pierre Kuhn

During the Journées Francophones deRecherche en Néonatologie SFN-JFRN
congress 2021, the Scientific Council of theFrench Society of Neonatalogy awarded
the Apgar Prize of the Neonatologist of theYear to Professor Pierre Kuhn of the CHU of
Strasbourg. Professor Pierre Kuhn, through his
research on the sensibility of the premature
newborn, his participation in the developmentof the European Standards (EFCNI), and thecoordination of GREEN (Groupe de Réflexion
et d’Évaluation de l’Environnement desNouveau-nés), is a tireless advocate of thevalues and practices inspired by NIDCAP
which has been practiced at the University
Hospital of Strasbourg for many years.

Professor Pierre Kuhn

Many congratulations to Pierre Kuhn, MD
and his team.

Developmental

ObserverThe official publication of the NIDCAP Federation International
published on-line three times a year. © 2022. The statements andopinions contained in this publication are solely those of the individual
authors and contributors and not necessarily of the NIDCAP Federation
International. Articles from the Developmental Observer, duly
acknowledged, may be reprinted with permission. Please contact us at:
developmentalobserver@nidcap.org.
Contributions
We would like to thank all of our individual donors for their generous
support of the NFI and its continuing work.

Articles are welcome for peer review andmay be submitted via the ScholarWorkssite or send directly to the Senior Editor.

The submission guidelines are available
on the ScholarWorks site.

Developmental Observer current and pastissues from: https://scholarworks.iu.edu/journals/

ISSN: 2689-2650 (online)

All published items have a unique document identifier (DOI)

2022 • Developmental Observer • 5

PRESENTED ABSTRACTS — NIDCAP TRAINERS MEETING 2021

Predictive Relations between Pre-discharge APIB Scores andPostterm General Movement (GM) Assesment in Very Low Birth
Weight Infants
DOI: 10.14434/do.v15i1.33775
Fujimoto T 1, Ogaki A1, Inoue T 1, Kawai T 1, Tanaka M 1,
Kugo M 2, Browne J 3
1

Rehabilitation Department, Japanese Red Cross Society Himeji Hospital,
Himeji, Hyogo, Japan

2

Pediatrics, Japanese Red Cross Society Himeji Hospital, Himeji, Hyogo, Japan

3

Pediatrics and Psychiatry, University of Colorado School of Medicine,
Aurora, Colorado, USA

BackgroundNon-invasive assessments of at-risk infants are important tools
for recognizing individual needs for support and intervention,
as well as the prediction of such needs. The APIB (Assessmentof Preterm Infant’s Behavior) is a sensitive technique for assessing prematurely born infants at early ages1 and, similarly, theGMs (General Movements) assessment at two – four months
corrected age is used to predict developmental disorder.2 APIB
is based on the Synactive Theory and the NBAS (Neonatal Behavioral Assessment Scale).3 It is a neurobehavioral battery thatyields a panel of multicomponent “packages” reflecting the status of various physiological and regulatory systems in preterm
infants. The GM’s greatest predictive value is around threemonths postterm (in the “fidgety” GM stage). The GM evaluation of Hadders-Algra yields a Gestalt evaluation of movement
complexity and variation, ranking infants as manifesting normal-optimal GMs (NO), normal-suboptimal GMs (NS), mildly
abnormal GMs (MA), or definitely abnormal GMs (DA).
Aims

The aim of this study was to test whether there are systematic
relations between APIB system scores before discharge andthose of the GMs assessment around three months corrected
age. If there are reliable associations between the two measuring tools, the extra predictive powers may prove valuable toearly detection of individual needs and to help guide intervention, remediation, and enhance developmental care.
Subjects and Method

Among the very low birth weight (VLBW) infants admitted
to our NICU/GCU from June 2019 to January 2021, 24 cases(10 boys, 14 girls, average birth weeks 29.7 ±3.2 weeks, averagebirth weight 1143.3 ± 248.6 g) were selected. They were thecases in which APIB could be performed before discharge, andGM assessment performed around three months corrected
age. Excluded from the sample were infants with neurologicalabnormalities such as hypoxic-ischemic encephalopathy(HIE) and periventricular leukomalacia (PVL). We used themode of the post package status score of the APIB systemscores and summary score derived before discharge (mean

6 • 2022 • Developmental Observer

39.3 ± 1.4 weeks). We conducted the GM assessments aroundthree months corrected age (average 3.1 ± 0.6 months); theclassification of Hadders-Algra was used to evaluate in stages with NO as 4, NS as 3, MA as 2, and DA as 1. Then, we
examined quantitatively the relations between APIB’s post
package status score and summary score, and GM assessments.
The APIB procedure and scoring was performed by an APIB
Professional; the GM assessments were conducted by threephysiotherapists with GM training. Statistical examination was
carried out using Spearman’s rank correlation coefficient (rs),and the risk factor p <0.05 was statistically significant.
Results

There were statistically significant correlations between the
APIB’s physiology and regulatory systems post package statusscores and GM assessments (physiology system: rs = -0.46, p<0.05; regulatory system: rs= -0.44, p <0.05). In contrast to thesefindings, no significant relations were found with the scores ofmotor system, state system, attention/interaction system, and examiner facilitation. Also significant was the relation of the APIB
summary score and the GMs assessment (rs = 0.47, p <0.05).
Conclusions

We found that APIB scores of the physiology and regulatory
systems status in VLBW infants in the NICU/GCU predicted
their General Movements GM scores at about three months
corrected age, during the so-called fidgety period. Not only
does the finding suggest the possibility of enhanced prognosis of developmental disorder, but it helps point to specificdevelopmental systems that can be targeted for intervention.
Furthermore, these findings also suggest that the physiology
system and regulatory system in the neonatal period may
affect the subsequent development. Nevertheless, the GMs
assessment may be influenced by state.2 Thus, we may examine
whether stable autonomic function, high self-regulation, andgood wakefulness may help explain the pattern of the results.
In the future, measures of variability in different infant populations could help clarify such interpretations. Regardless, thepresent findings elevate the efficacy of a synactive-based method to link to another diagnostic tool for increased predictive
power of the need for developmental support.
References
1. Als H, Butler S, Kosta S, & McAnulty G. The assessment of preterm infants’ behavior(APIB): Furthering the understanding and measurement of neurodevelopmental competence in Preterm and Full-Term Infants. Ment Retard Dev Disabil Res Rev. 2005; 11(1):
94–102.
2. Hadders-Algra M. General movements: a window for early identification of early identification of children at high risk for developmental disorders. J Pediatr; 2004;145:S12-S18
3. Brazelton TB and Nugent JK. 2011. The Neonatal Behavioral Assessment Scale.
Mac Keith Press, Cambridge.

PRESENTED ABSTRACTS — NIDCAP TRAINERS MEETING 2021

NIDCAP Rounds: Reaching More Babies and Families
Giesen J 1, Campbell C 2
1

Speech Pathology and Audiology, Stollery Children’s Hospital, Edmonton,
Alberta, Canada

2

Occupational Therapy and Physiotherapy, Stollery Children’s Hospital,
Edmonton, Alberta, Canada

Aims

The purpose of this project was to institute developmental carerounds in our NICU. The premise for the project arose when,
upon completion of training to become a NIDCAP Professional, this writer posed the question, “Now that we’ve completed training, how do we reach more babies in our limited
time? What does it look like in practice?” The aim was to work
together with families to learn how to interpret their babies’communication, to support their babies’ positions, touch them,talk to them, and hold them in a way that they are able toattend, respond, and interact socially.
Methods

The ENTCC (Edmonton NIDCAP Training Centre Canada)
and rehabilitation therapists at the Stollery Children’s Hospitalteamed up to develop a plan for instituting NIDCAP Rounds.
These were set to occur for two hours every two weeks from
October 6, 2020 to the present, excluding holidays. NIDCAP certified participants would include a speech language
pathologist (SLP), occupational therapist (OT), and another
NIDCAP certified member (nurse, neonatal nurse practitioner,or neonatologist) when available. Eligibility for family participants included those who were:a)available for roundsb)and interested in working with the team to learn more
about their babies, how to connect with them, and how to
support their development andc)and expected to require a long stay in the NICU
Input was elicited from head nurses and other NICU
team members to select families to approach for NIDCAP
rounds. The plan was to visit with three families each round.
At the start of each round, one team member would introduce
NIDCAP and the premise of rounds, providing a handout tofamilies for reference. Families were encouraged to describe
their babies, what they showed them in their behaviour, theirstrengths, current challenges, concerns, and where they’dlike support. The team would perform a joint short, guided
observation, bring parent and baby together, and coach parents
in providing supports. Team members would then work withfamilies to devise specific developmental care goals for theirbabies. The goals were recorded in the patient’s chart andreviewed with bedside staff.

DOI: 10.14434/do.v15i1.33775

Results/Findings

NIDCAP Rounds were conducted 15 times in nine months
with 25 families participating. Seven families participated in
two sessions and 18 in one session. NIDCAP Rounds wereattended by SLP (14 times), OT (14 times), neonatologist(4 times), and neonatal nurse practitioner (one time).
Developmental care goals addressed included:• hold baby skin-to-skin (4)• support baby to come to alertness by speaking/singing inparents’ first language (8)• support baby to fall asleep by hand swaddling and protect
sleep by keeping noise, lights, and activity low (5)• provide positioning supports to help baby maintain a comfortable flexed position in bed (4)• nuzzle at a pumped breast whenever alert and rooting (3)• implement supportive feeding strategies (swaddle, elevatedside-lying position, gentle burping, pacing, hold uprightduring tube feeds) in order to support positive oral experiences (8)• schedule interventions when parents available to provide
support (3)• gradually reduce rolls and start day/night routine in preparation for transition home (9)Relevance to NIDCAP

This project addresses the NIDCAP Nursery Program categories of the nursery environment and care of the infant, family,
and professional healthcare team.
Conclusion

By implementing NIDCAP rounds, we were able to use a small
time-commitment to meet with many families.
NIDCAP observations led to parents and staff partnering todefine infants individualized developmental goals.

NIDCAP Trainers Meeting Feedback“It was rewarding to see the work
NIDCAP is achieving.”

2022 • Developmental Observer • 7

PRESENTED ABSTRACTS — NIDCAP TRAINERS MEETING 2021
DOI: 10.14434/do.v15i1.33780

The APIB Examination in the NICU: Its Clinical Use
Tyebkhan JM 1,2,3
1

Stollery Children’s Hospital2

Dept of Pediatrics, University of Alberta

3

Edmonton NIDCAP Training Centre Canada (ENTCC).

Background

The Assessment of Preterm Infants’ Behavior (APIB) is a
structured, neurobehavioural examination that objectively
measures neurobehavioural functioning. Preterm infants who
have received NIDCAP care have improved neurobehavioural
outcomes by APIB scores; these APIB measures correlate with
developmental function at older ages.
Reliability in APIB administration and scoring is requiredfor certification as a NIDCAP Trainer. The examination
requires time, physical and emotional energy on the part ofthe examiner, who facilitates the infant into his / her most
responsive, modulated state. Infant response patterns must be
clinically relevant, although we do not know if APIB is used inthis way.
Aims

I will present my experience of ‘Clinical APIB’ and the surprising benefits for babies, families, and staff, and for the NICU
System. I hope to promote interactive discussion about clinicaluse of this informative instrument.
Relevance to NIDCAPAPIB helps us see infant neurobehaviour “in 3D”, making the
NIDCAP observation simpler, while revealing more detail.
If more NIDCAP professionals/ NICU staff know the APIB,
this will positively impact NIDCAP training and thus directly
affect the Physical Environment and the Care of the Infant,Family and Staff.

interaction). Parents were provided narrative summaries withsuggestions for caregiving, similar to a NIDCAP report.
Results

All babies demonstrated neurobehavioural strengths. Somewere surprising: e.g., a severely asphyxiated, “completely unresponsive” infant oriented to mother’s voice when guided to
speak in synchrony with the baby’s unique neurobehaviouralthresholds. Other surprising strengths included habituation
to light and noise, and the quality of sleep. Staff education wasenhanced as a result.
APIB led to fewer investigations and interventions, andearlier discharge. For example, (A) Home oxygen for a late
preterm infant who was having more frequent apnea and desaturations. APIB done with parents helped guide “in synchrony” caregiving and feeds; apnea resolved, and baby was discharged home, without oxygen, 2 days later. (B) Three preterm
infants who had early post-hemorrhagic ventriculomegaly
were felt to be appropriately responsive for age; neurosurgery
was avoided (n = 1) or delayed (n = 2).
APIB allowed early detection of neurologic findings, e.g
asymmetry of movement and /or unusual patterns of tone notdetected by others, leading to early intervention referral.
Conclusions

Clinical APIB revealed neurobehavioural strengths and challenges that had otherwise been missed. Clinical APIB led tochanges in clinical care and use of NICU resources.

Methods

APIB is structured in six sections (“packages”), some of which
are directly applicable to the infant’s everyday experience in
the NICU. Replace with For example, Package 1 assesses responses to light and noise, during sleep. The clinical question is“How does this baby sleep, in this bedspace, within this NICU”.
Package 2 assesses responses to being unbundled and turned
supine – which occurs repeatedly during diaper changes.
Package 6 evaluates social attention and interaction;
directly relevant to feeding and interactions with parents.
APIB exams were done at different time points during
infants’ NICU stays. Some exams were video recorded, if
parents consented. APIB exams were done at bedside, or in aquiet, dark room. Parents were invited and informed about theexam flow, time required and what to expect of their babies. At
times, parents were invited to participate in Package 6 (social
8 • 2022 • Developmental Observer

NIDCAP Trainers Meeting Feedback“Congratulations to the organizing
committee led by Fatima Clemente
and Jean Powlesland.”PRESENTED ABSTRACTS — NIDCAP TRAINERS MEETING 2021
DOI: 10.14434/do.v15i1.33781

Family Centered Music Therapy for Preterm Infants and Their
Parents in the NICU: A Mixed-Method Study
Yakobson D 1,2, Elefant C3, Litmanovitz I 1,4, Bauers S 1,4,
Arnon S 1,41

Neonatal Department, Meir Medical Center, Kfar Saba, Israel

2

Doctoral Program in Music Therapy, Institute for Communication andPsychology, Aalborg University, Denmark

3

School for Creative Arts Therapies, University of Haifa, Israel

4

Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

Background

Preterm infants experience noxious stress during their NICU
hospitalization. Unbuffered stress may negatively influence
their autonomic nervous system (ANS) maturation thus effecting neurobehavior and development.1 Music therapy (MT)is an evidence-based intervention used in neonatal settings.2
When coupled with skin-to-skin care (SSC) it may reducestress responses in both preterm infants and their parents andenhance family-centered care.3,4 Few studies have investigatedthese interventions combined, and evidence of longer-term
effects is missing.
Aim

To investigate the effects of combined, family-centered MT
and SSC on preterm-infants’ ANS stability and their parents’mental well-being.
Methods

An embedded mixed-methods design was used.5 A single-center, cluster-randomized trial with two parallel arms was conducted. Ten time-clusters of two months, each with five - eightparticipating families, were randomized to either combined
MT+SSC or SSC alone. Sixty-eight families were offered two
weekly sessions of the allocated condition in the NICU, anda follow up at home at three-months corrected age (CA). The
primary outcome was stabilization of the ANS as defined bychange in the high frequency component of heart rate variability during the second session. Secondary outcomes included
additional HRV measures, attachment, and parental anxiety.
Outcomes were analyzed on an intention-to-treat basis using
linear mixed-effects models.
A qualitative exploration of parents’ experiences regarding MT sessions was performed. Ten parents participated insemi-structured interviews at four-months CA. Data was analyzed using thematic analysis methodology within a reflexive
hermeneutic approach.
The MT intervention was based on the “First sounds:
Rhythm, Breath and Lullaby” model6, which focuses on theparent-infant dyad. Key elements include specific attention to
infant’s cues, parent, and environment, and to their reciprocalinteraction; rhythmic entrainment; use of parents’ voice andmusical heritage; and encapsulating the sounds of the intrauterine environment. Guidelines for the intervention affordedhigh flexibility to address alternating parental or infants’ needs,
and to offer additional means for musical engagement.
Results/Finding

MT+SSC improved infants’ ANS stability, as indicated by agreater increase in HF power (mean difference 5.19m2/Hz,
SE=1.27, p < 0.001) (95% confidence interval 0.87 to 2.05), as
compared to SSC alone. HF power is an indicator of a relaxedstate in the ANS, representing improvement in autonomic
regulation, which highly impacts preterm-infants’ processes ofrecovery and maturation.7
Other HRV indices as well as parental anxiety showeda nonsignificant tendency favoring MT+SSC condition.
Main themes derived from parents’ interviews revealed that
MT+SSC sessions were perceived as unique moments solely
dedicated to connecting with their baby, and as such, essentially different from daily medical routines. Singing was experienced as means to provide “something deep from within themselves” and enhanced feelings of self-coping by overcoming
personal difficulties. Parents reported that MT has promoted
relaxation for both them and their baby, leading to feelings ofintimacy and being-in-the moment. MT informed and motivated their use of music throughout the hospitalization period
and was incorporated into their everyday lives.
Relevance to NIDCAP

This study relates to core components of the NIDCAP model,
namely, modulation of stress in the NICU, promotion of infant’s behavioral organization, and enhancement of early parent- infant bonding.8 Implementation of family centered MT
during SSC might provide additional opportunities to enhancestability, intimacy, and bonding in the NICU.
Conclusions

Combined MT+SSC contributes to preterm-infants’ ANS
stability and stress reduction, laying an important foundation
for neuro-behavioral and psycho-emotional development.
Family- centered MT is highly attuned to parents’ and infants’needs and may support the dyad to engage musically and enhance meaningful interactional moments during hospitalization. Studies evaluating longer-term effects of MT on preterm
infants’ development are warranted, as well as the investigationof longer therapeutic processes and their impact on parents’experiences.
(References on p. 27)
2022 • Developmental Observer • 9

PRESENTED ABSTRACTS — NIDCAP TRAINERS MEETING 2021

NIDCAP: A Psychoneuroendocrine Perspective

DOI: 10.14434/do.v15i1.33777

1

Department of Psychology and Gonda Brain Research Center, Bar Ilan
University, Israel.

2

Department of Psychiatry, Boston Children’s Hospital and Harvard Medical
School, USA

3

Department of Neonatology, Schneider Children’s Medical Center, Sackler
Medical School, Tel Aviv University, Israel.

may suggest that hypothalamic regulation works in concert
with the epigenetic effects to bring about an optimal range ofreceptor availability if supported by optimal environmental
inputs. Reduction of stress may bring about compensatorytranscription processes in the hypothalamic pathways. Thus,
ameliorative alterations of the epigenome are possible withbalanced environmental inputs.4,5

Aims

Relevance to NIDCAP

Goldstein Ferber S 1, McAnulty G2, Klinge G3, Weller A1,
Als H2This presentation outlines the pathways through which
NIDCAP promotes hypothalamic control of cognitive development by attenuating inevitable NICU stress, thus regulating
over-arousal, flaccidity, and shutdown.
Methods

By integrating past decade’s research on the hypothalamus andpreterm infants.
Results

HPA -Three hormones regulated by the HPA, Melatonin,
Cortisol and Oxytocin, are implicated in the preterm infant’s
NICU experience: Melatonin as regulator of circadian rhythm
maturation and in turn influencer of cognitive development1(Bayley Scales); Cortisol as regulator of stress modulation, andOxytocin as mediator of parent infant affectionate relationshipand bonding. Moreover, preterm newborns lack the capacity
to generate a full adrenocortical response to stress or illness,
which conversely, later in development turns into a disproportionate increase in glucocorticoid action and over-arousal
states.
HPT - Congenital hypothyroidism is frequently associatedwith the development of intellectual disability. Often it isinvolved in the association of lower gestational age at birth andimpaired cognitive and self-regulation functioning later on.2 In
addition, inadequate HPA stress regulation in preterm infants
further compromises their HPT function through HPA-HPT
cross-connectivity.
HPG - Fluctuations of progesterone and estrogen levels are
relevant for females’ optimal HPA reactivity. In males, earlyprograming of testosterone levels affects HPA and testosterone
reprogramming during puberty and is necessary for adaptive
HPA reactivity in adulthood.3
Thus, all three axes of the hypothalamus and their ‘crosstalk’ are relevant, either by direct or by secondary impact,3 tothe understanding of prematurity and its resulting compromised cognitive and self-regulation development. The variability documented in the methylation of the genes of thesemetabolic neurochemicals’ receptors, OXTR, NR3C1 and Nrf2,

10 • 2022 • Developmental Observer

By affecting stress reactivity and the HPA, NIDCAP methods
appear to affect the function of the hypothalamic axes, whichshow association and causality pathways with cognitive andself-regulation functions. It is postulated that feedback mechanisms and correction signals of hypothalamus-based homeostatic modulating functions account for the stress reduction
brought about by very early NIDCAP intervention.
Conclusion

The balancing effects of NIDCAP are fed back to the hypothalamus for correction of the signaling to prefrontal cortex, theseat of executive functions. Given their bi-directional pathways, in turn the neuro-hormone and neuropeptide production levels adjust accordingly.
References
1. Ferber SG, Als H, McAnulty G, Peretz H, Zisapel N. Melatonin and mental capacities
in newborn infants. Journal of Pediatrics. 2011, 159(1):99-103.e1. DOI. 10.1016/j.
jpeds.2010.12.032
2. McBryde M, Fitzallen GC, Liley HG, Taylor HG, Bora S. Academic outcomes of schoolsged children born preterm: A systematic review and meta-analysis. JAMA Network
Open. 2020, 3(4):e202027. DOI: 10.1001/jamanetworkopen.2020.2027.
3. Oyola MG, Handa RJ. Hypothalamic–pituitary–adrenal and hypothalamic–pituitary–gonadal axes: sex differences in regulation of stress responsivity. Stress. 2017 Sep;20(5):476494. DOI: 10.1080/10253890.2017.1369523
4. Goldstein Ferber S, Trezza V, Weller A. Early life stress and development of the endocannabinoid system: A bidirectional process in programming future coping. Dev Psychobiol.
2021, 63(2):143–52. DOI:10.1002/dev.21944
5. Ferber SG, Roth TL, Weller A. Epigenetic fragility of the endocannabinoid system understress: risk for mood disorders and pharmacogenomic implications. Epigenomics. 2020,14(8):657-660. doi.org/10.2217/epi-2020-0037

NIDCAP Trainers Meeting Feedback“We would like to see more clinicalpractice sessions, open discussion
around APIB and small discussion
groups.”ABSTRACTS — NIDCAP TRAINERS MEETING 2021

NICU “graduates” Follow-up: Goals Achieved and Future
DOI: 10.14434/do.v15i1.33778
Perspectives of a NIDCAP Team
Papa I, Montesi A, Grandi S, Mandolesi R*, Simeone N,
Ancora G
NICU AUSL Romagna, Ospedale Infermi, Rimini, Italy*

Trainee at the Bologna School of Cognitive Psycotherapy

Background

Preterm infants require individualized care and family support
after NICU discharge, both to close the gap from discharge
to first follow-up appointment, and to support neurodevelopment throughout the first 1000 days from conception. EFCNI’s
Standards of Care emphasize the need of a multidisciplinary
follow-up (FU) program for premature infants after NICU
discharge. A fundamental component of good nurturing
care is supporting parents to be co-regulators in their child’s
neurodevelopment. Parents of premature infants are at highrisk of short- and long-term mental health difficulties, partly
due to an abrupt change in the caregiving environment after
discharge - from a highly supportive environment in the NICU
to a relatively isolated home environment - especially during
the COVID-19 pandemic.
Aim

To describe a new modality used in our preterm infants FU
program, which incorporates NIDCAP-based principles ofcare.
Methods

Since 2015, our FU program has been reorganized as follows:
application of the NIDCAP approach, combined with structured neurobehavioral evaluations (which includes naturalistic
observations of parent-infant interaction and the Hammersmith Infant Neurological Examination (HINE)) and a
NIDCAP observation report for the family in which theinfant’s strengths, achievement of neurodevelopmental
milestones, future challenges, and key recommendations areemphasized. This reorganization was possible because the FUteam included NIDCAP professionals and trainees. The FU
evaluation also includes two psychologists to support the families and to administer psychometric tests to infants. The FU isscheduled at 3, 6, 12, 24 and 36 months of corrected age (CA).
Bayley Scale of Infant Development III ed. (BSID) is administered at 12, 24 and 36 months CA.
Results

Since 2015, 173 ELBW-VLBW attended the FU program. Prevalence of cerebral palsy was 5.2%, according to Gross Motor
Function Scale (9/173), lower than previously reported for acomparable population in literature (10-15%). BSID data werecollected from 171, 127, and 80 infants at 12, 26 and36 months CA, respectively. Poorer outcomes were correlatedwith lower gestational ages (GA). Cognitive scores <= 75 weredetected in about 5% of cases (9/171 at 12 months CA, 6/127
at 24 months CA, 4/80 at 36 months CA).
Single infant’s neurodevelopmental trajectories showed
an improvement of BSID motor scores through the years
even at lower GAs. However, up to 25% of infants showed low
performance scores at 24 and 36 months CA in the expressive
domain of BSID language scale.
During the same period, our NICU transitioned fromstandard care to NIDCAP-based care and a NIDCAP Training
Centre opened in 2020.
Relevance to NIDCAP

Developmental care is to be continued long after NICU discharge, in order to support parents in providing appropriate
developmental experiences to their infants. A NIDCAPtrained team in the FU program afforded the continuation ofindividualized family centered care for parents and infants
long after discharge.
Conclusion

Improvement in single infants neurodevelopmental motor
trajectories, low prevalence of poor cognitive outcome andcerebral palsy (CP) were observed during a FU that included
the principles of the NIDCAP care for infants and families also
after discharge from NICU.
To enhance individualization and multidisciplinary
support in the follow-up program, future steps in our Unit willbe the introduction of videotaped naturalistic observations,
APIB assessments and measurement of parents’ perceived
experience.
Investigation of the role of the application of the NIDCAP
approach during the follow-up period deserves future studies.

NIDCAP Trainers Meeting Feedback“We are challenged to integrate
research findings into NIDCAP work.”

2022 • Developmental Observer • 11

ABSTRACTS — NIDCAP TRAINERS MEETING 2021

NIDCAP Partners with Industrial Design: Training for Success
Tybekhan JM 1,2,3, Van der Leek C 4, Gustin B 4, Salamon K4,
von Hauff P5
1

Stollery Children’s Hospital2

Dept of Pediatrics, University of Alberta

3

Edmonton NIDCAP Training Centre Canada (ENTCC)

4

Dept of Industrial Design, University of Alberta

5

Academic Technology, Faculty of Medicine and Dentistry,
University of Alberta. (All located in Edmonton, Canada)

Background

The NFI’s Strategic Plan (2017) includes “Strengthening
NIDCAP training processes” and “Expanding NIDCAP education and training resources”.1 NFI members discussed ‘Training Materials and Pathways’ at the NIDCAP Trainers Meeting2019.2 However, constraints of time, people-power and resources mean that a logical starting point for the developmentof enhanced Training Materials has not yet been defined.
Coincidentally, the Edmonton NICU has been exploring
the creation of an online educational platform with the Departments of Academic Technology (AT) and Industrial
Design (ID) at the University of Alberta (U of A). This platform could host specialized training programs offered in
Edmonton – one of these being NIDCAP.3
AT and ID at U of A have previously developed educational material for use in clinical settings, e.g. neonatal resuscitation,4 electronic portfolios.5 Some of this work is distinctly
family-focused, e.g. 3-D models of the heart to help families
and learners understand the anatomy of congenital cardiac
anomalies.6 Learning about this work led to the first meetingof our study team. AT faculty and ID students quickly grasped
the essence of NIDCAP and three students devoted their finalpracticum to this project.

Methods

DOI: 10.14434/do.v15i1.33779

Primary research methods included interviews, and the useof convergent and divergent design thinking, using a ‘Double Diamond’ diagram (Figure 1). The Double Diamond is acommon design model used to showcase different thinking
skills throughout a design process. ID students visited the Edmonton NIDCAP Training Centre Canada (ENTCC) to gain
an understanding of the NIDCAP Training framework, andthe intricate relationship of Trainer and Trainee. They toured
the NICU to see ‘NIDCAP in Action’. Further insights wereobtained through interviews with members of ENTCC and theEdmonton NICU Program. The ID approach of interviews anddesign-based methodology enabled critical analysis and distillation of the multilayered steps of NIDCAP Training. Creating
a series of Spider Diagrams enabled the delineation of areas ofintervention and existing relationships within the NIDCAP
Training pathway, (Figure 2). This led to a practical, defined
starting point for a small change that could have great impact.
FIGURE 1 - A Design Process: Convergent and Divergent
Thinking Diamond

Aims/Purpose

ID brings an interdisciplinary approach to improve the qualityof experience and to overcome challenges, using profession-specific analytical methods. The aim was to use the ID
perspective to create a model to serve NIDCAP in a contemporary, globalised context. For this first phase of our collaborative project, ID students focused on the educational pathway of
NIDCAP Training, i.e. preliminary readings, didactic lecture,individual training, Advanced Practicum of NIDCAP training,and certification.
Relevance to NIDCAPNIDCAP is a training program. Augmenting the success of
this training will directly impact clinical care and improve theoutcomes of hospitalised newborn infants. This project directly
addresses some of the NFI’s Strategic Goals.1

12 • 2022 • Developmental Observer

Results/Findings

The study team agreed early in the process that a functional,
on-line learning platform could not be created without thispreliminary work. ID methodology led to a practical first step
towards enhanced NIDCAP Training: “How can the NIDCAP
Observation Sheet be made easier to learn?” The sequential stages that led to this result will be explained during thepresentation. The goal was not to change the existing Observation Sheet; making this easier for trainees would be similar topractice exercises for learning the use of a computer keyboard.
Conclusions

ID methodology applied to the NIDCAP Training Pathway
found that the NIDCAP Observation Sheet is a logical firstABSTRACTS — NIDCAP TRAINERS MEETING 2021

FIGURE 2 - Preliminary Prototype
A Spider Diagram used to Illustrate Multiple Relationships
within a Design Problem. This diagram illustrates a step along
the process of arriving at our proposed design solution.

point for adaptation. This conclusion could provide focus for
the NFI’s Next Steps related to Training Materials and Pathways. Further work should explore such adaptation(s), withrespect to the educational experience and success of training.
Collaboration with AT, ID and other professions could help
accomplish NFI Strategic Goals.
References:
1. NIDCAP Federation International (NFI) Strategic Plan (2017). Available at <nidcap.
org/wp- content/uploads/2017/12/2017-Strategic-Plan-Adopted-Oct2017-minor-edits-Nov-2017.pdf>

2.
3.
4.
5.
6.

Silberstein D and Tyebkhan JM. Summary Document ‘Topic 3 - Training Materials andMethodologies; Summary and Action items from NIDCAP Trainers Meeting 2019’.
Available on request from J Tyebkhan
Specialty neonatal training offered in Edmonton includes Mindfulness in the NICU andTargeted Neonatal Echocardiography
Ghoman SK, Cutumisu M, Schmölzer GM. Simulation-based summative assessment of
neonatal resuscitation providers using the RETAIN serious board game-a pilot study.
Front Pediatr 2020 Jan 31;8:14. doi: 10.3389/fped.2020.00014. eCollection 2020
Sonnenberg L, von Hauff P, Lemieux L. Electronic portfolios for assessment in postgraduate medical education. Med Ed Publish, 2017. Available at https://doi.org/10.15694/
mep.2017.000066
Larson C et al. See https://edmontonjournal.com/news/local-news/heart-transplantmodel-takes-star- wars-shape2022 • Developmental Observer • 13

NIDCAP TRAINERS MEETING 2021
DOI: 10.14434/do.v15i1.33782

Journal Club Presentation:

Is Medical Education Ready for Generation Z?
Chabba R, Tyebkhan J
Edmonton NIDCAP Training Centre Canada (ENTCC)
Citation: Eckleberry-Hunt J, Lick D, Hunt R. Is medical education ready for
generation Z. J Grad Med Educ. 2018;10(4):378-381

The article begins by pointing out how medical education
should plan to make adaptations based on how different Generation Z is from other generations.
Generation Z are those born between 1995 and 2012.
They are the only generation that has always had access tothe internet and social networking, and hence have a hardtime disengaging from technology. They are hardworking andindependent in their learning but also prefer close mentoring
relationships. Having always had access to technology andthe internet, they want to know what they need to know inthe moment and prefer not to spend long hours listening tolectures. Rather than the traditional approach to medical education, these students will both need and expect a customized
experience.
Generation Z is known to have a shorter attention spancompared to other generations, and expect material presented
to them to be engaging. Since retrieving information has always been so easy for this generation, they lack the skills to beable to evaluate information and will need help to do so.

The authors suggest education of Generation Z should
include modern technology, and creative modalities such as
podcasts and simulations. This generation also expects quick
and personal feedback. Active learning methods includingreflection and discussion will be more useful with this generation versus traditional lectures.
The authors conclude by reminding us that the goal should
always be to ensure quality patient care as we consider making
these changes, although historically, medical education has
been hesitant to make reforms.
Relevance for NIDCAP• The youngest parents and new staff coming into the NICU
are Generation Z and will want to receive information as
described by this article.
• The NIDCAP model involves observation and sharing thatobservation in a detailed narrative report to both staff andpatients. Based on the findings of this article, both staff andpatients may not engage with this material thus suggesting
there is an immediate need for change.
• The new generation of NIDCAP trainees are likely to prefermore creative ways of sharing their observations. We suggest that these creative ways are embraced by the NFI.

Journal Club Presentation:

DOI: 10.14434/do.v15i1.33783

Early Parenting Intervention – Biobehavioral Outcomes in Infants
with Neurodevelopmental Disabilities (EPI-BOND): Study Protocol
for an Italian Multicenter Randomized Controlled Trial
Thergaonkar N.
Aaroha Centre for Psychological Services, Mumbai, India
Citation: Montirosso R, Rosa E, Giorda R Early Intervention Study Group, et
al Early Parenting Intervention – Biobehavioral Outcomes in infants with
Neurodevelopmental Disabilities (EPI-BOND): study protocol for an Italianmulticentre randomised controlled trial BMJ Open 2020;10:e035249. doi:
10.1136/bmjopen-2019-035249

Overview

Infants with neurodevelopmental disability are at risk foraltered behavioral and socio- emotional patterns. The present
longitudinal, multi-center interventional clinical trial aims at
assessing the effectiveness of an early parenting intervention
based on video-feedback technique (VFI) to support maternal
responsiveness (parental sensitivity) and the socio-emotional
14 • 2022 • Developmental Observer

development of infants with developmental disabilities using
a multi-layer approach to outcomes assessment (behavioral,
neuroendocrine and epigenetic outcomes).
The study plans an estimated enrollment of 180 participants, randomized into parallel assignment intervention modelwith double masking participant, outcome assessors. The study
start date was September 2019 and estimated completion date
was December 2021.
Study design

Inclusion criteria• Infants: Age range 3-18 months with mild- moderate psychomotor delay

NIDCAP TRAINERS MEETING 2021

• Mothers: Age > 18 years, living with the father of the infant
and mastery of Italian language
Exclusion criteria• Infants: Presence of severe sensory deficits and genetic syndrome with known functional implications for epigenetic
regulation of target genes• Mothers: Documented mental disorder and documented
disability
Methodology• The intervention group will include dyads of mothers andtheir infant with developmental disability who are exposedto the VFI focused on different domains of mother-infantquality of interaction (number of sessions: 6)• The control group will have dyads of mothers and theirinfant with developmental disability who will receive phone
calls focused on obtaining descriptions of different domains
of infant behavioural development instead of the VFI,
(number of sessions: 6).

Primary outcome measure:• The study will have four assessment sessions: T0- baseline, T1- Post intervention, T2- Short-term follow-up (3months) and T3- long-term follow-up (6 months).
• Improvement of infants’ behavioural and socio-emotional
regulation will be measured by GRS coding system, basedon infant behavioural regulation as well as Face-to-Face
Still Face (FFSF) double exposure paradigm from a 10 minute unstructured mother- infant interaction with standard
set of toys.
• Developmentally supportive parental behaviour (maternalsensitivity) will be assessed by the PICCOLO coding system

Journal Club Presentation:

as well as Face-to-Face Still Face (FFSF) double exposure
paradigm from a 10 minute unstructured mother-infantinteraction with astandard set of toys.
• Salivary samples of mother and infant for cortisol and oxytocin will be collected at each assessment session (additional samples for infants will be taken at 15 (reactivity) and 30(recovery) minutes after the FFSF procedure.
• Change in hormones and capital Salivary oxytocin concentrations will be assessed for differences between and withingroup by generalized linear model.
• The hypothalamic-pituitary -adrenal (HPA) axis stressregulation will be assessed in terms of direction and magnitude.
• DNA methylation of target genes will be assessed at specificCpG sites by separate saliva samples of infants for epigenetic analysis at the end of the FFSF procedure.
Feasibility outcome measures• Feasibility of the interventions will be assessed by ‘acceptance of the intervention’ and ‘maternal experience’ with
VFI rating scales from mothers, at T1.
Relevance for NIDCAP• Brings new evidence to promote early intervention formothers of infants with developmental disabilities.
• Provides a common early intervention program to optimize
healthcare costs.
• Introduces an innovative approach to early parenting intervention for families of infants with developmental disabilities by studying the epigenetic variations.

DOI: 10.14434/do.v15i1.33784

Thematic Brief: Nurturing Care for Every Newborn
Westrup B.
Co-Director Karolinska NIDCAP Training & Research Center.
Dept of Neonatology; Astrid Lindgren’s Children’s Hospital Karolinska
University Hospital
Dept Women’s & Children’s Health, Karolinska Institute
Citation: World Health Organization, United Nations Children’s Fund, WorldBank Group. Nurturing care for every newborn (in progress). Geneva: World
Health Organization; 2021.

Summary

The first hours, days and weeks after birth are a precious time
for a newborn’s survival, health and development. Knowledge

and tools are available to provide every newborn with nurturing care that involves parents and other caregivers directly. To
create the enabling environment for providing such care, there
is a need to invest in policies, health systems and community
awareness. As more newborns survive, we now need to makesure that they also thrive. This is especially important for thoseat greatest risk: small and sick babies who are more likely todie or suffer more illness. This Thematic Brief summarizes
why nurturing care is essential for every newborn. Nurturing
care comprises five interrelated and indivisible components:
good health, adequate nutrition, safety and security, responsive
2022 • Developmental Observer • 15

NIDCAP TRAINERS MEETING 2021

caregiving and opportunities for early learning. Nurturing carehappens when we maximize every interaction with a child. Every moment, small or large, structured or unstructured, is an
opportunity to ensure children are healthy, receive nutritious
food, are safe and learning about themselves, others and theirworld. What we do matters, but how we do it matters more.
Nurturing care protects children from the worst effects of adversity and produces lifelong and intergenerational benefits forhealth, productivity and social cohesion.
Comment

Nurturing care for early childhood development https://www.
who.int/activities/addressing- nurturing-care-for-early-childhood-development is a very important work developed incollaboration by World Health Organization, United Nations
Children’s Fund, World Bank Group – all organizations ofcourse with very high credibility and impact. This is their
thematic brief of nurturing care of the newborn planned to be
published in July 2021.
Relevance for NIDCAP/NFI

Many of us in the NFI have substantially contributed to thisimportant document through the work with the EFCNI standards of IFCDC (Infant- and Family Centered Developmental
Care) or directly by submitting narratives and pictures fromclinical practice of NFI affiliated NICUs. This document could
play a very important role in enhancing the dissemination of
the key values and recommendations of NFI globally in lowand middle- but also high-income countries.

NIDCAP Federation International Board of Directors and Staff 2021–2022
PRESIDENT

Deborah Buehler, PhD

NIDCAP Master Trainer
APIB Trainer
Director, West Coast NIDCAP and APIB
Training Center
email: nfipresident@nidcap.org
VICE PRESIDENT

Dorothy Vittner, RN, PhD

Fatima Clemente, MD

NIDCAP Trainer
Co-Director, São João NIDCAP
Training Center
email: clemente.fatima@gmail.com

Mandy Daly, Dip. H Diet andNutrition, ACII, DLDU

Family Representative, Dublin, Irelandemail: mandy.daly@yahoo.co.uk

Senior NIDCAP Trainer
West Coast NIDCAP & APIB Training
Centeremail: dvitt8@gmail.com

Jennifer Degl, MS

TREASURER

NIDCAP Trainer
Hospital Universitario 12 de Octubre
NIDCAP Training Center
email: mariamaestro@gmail.com

Gloria McAnulty, PhD

National NIDCAP Training Center
email: gloria.mcanulty@childrens.harvard.
edu
SECRETARYJean Powlesland, RN, MS

NIDCAP Trainer
Director, Children’s Hospital of University
of Illinois NIDCAP Training Center
email: jpowlesl@uic.edu

16 • 2022 • Developmental Observer

Family Representative, New York, USAemail: jenniferdegl@gmail.com

Maria Lopez Maestro, MD, PhD

Dalia Silberstein, RN, PhD

NIDCAP Trainer
Co-Director, Israel NIDCAP Training
Centeremail: dalia.silberstein@clalit.org.il

Juzer Tyebkhan, MBBSNIDCAP Trainer
Director, Edmonton NIDCAP Training
Centreemail: juzer.tyebkhan@albertahealthservices.ca

STAFF

Rodd E. Hedlund, MEd

Director, NIDCAP Nursery Program
NIDCAP Trainer
email: nidcapnurserydirector@
nidcap.org

Sandra Kosta, BA

Executive Director of Administration
and Financeemail: sandra.kosta@childrens.
harvard.edu
FOUNDER OF THE NIDCAP FEDERATIONINTERNATIONAL, INC.

Heidelise Als, PhD

NIDCAP Founder, Past President 2001-2012
Senior NIDCAP Master Trainer
APIB Master Trainer
Director, National NIDCAP Training Center
email: heidelise.als@childrens.harvard.
edu

SPONSOR PROMOTIONA New e-learning Program forDevelopmental care
NFI members get a 10% discount.
Fee $99 AUD, ($71 USD, Euro 63 approx.)
The link for First Steps FINE eLearning ishttps://schp.org.au/fineaustralia

We would liketo include morestories, poetryor reflections
from the NFI
membership.

Developmental

ObserverThe Official Publication of the NIDCAP® Federation International

2022 | VOL 15 | NO. 1

CALLING ALL MEMBERS OF THE NFI“To be able to carry a child isa gift, giving birth in Sweden
is a privilege, to be cared foraccording to NIDCAP is beyond
everything.”—Magdalena Persson Pettersen
and André Persson

FAMILY VOICES

Connection
is essential.
— Jacques Sizun MD

INSIDE
Family Voices ................................................ 1.
Editorial ............................................................ 4.
Member Achievements .................... 5.
Abstracts ......................................................... 6.
Journal Club Presentations ........ 14.

DOI: 10.14434/do.v15i1.33785

Magdalena Persson Pettersen and André Persson | Column Editor – Debra Paul, OTR/L

NIDCAP from a Parent’s PerspectiveIt was August 15th. Magdalena’s water
breaks and we travel at a high speed to thehospital. Early in the pregnancy we had
been told Magdalena could not sit, only lying
down. We are keeping positive thoughts. The
baby is healthy and is strong. Should we callbefore leaving for the hospital? Remember
the Vitamin K injection. We can do this! In achaos of thoughts, words, and exhortations between the contractions, we try to be brave andremind ourselves that “nothing has happened
before it happens”.
After a troublesome pregnancy, we are
finally here. The day when our boy decided to see the light of day. We arrive to thehospital. Like flies around a piece of sugar,
the hospital staff flocks around us and dotheir utmost to stop the contractions andskillfully manage to give us a break of afew hours. An obstetrician rushes into

the room to announce that a researchstudy on immediate skin to skin contact
directly after birth is being conducted at
the hospital and that we match the study
group, as we are now expecting the preterm
birth of our son. She gathers herself as if
she understood very well that this was notreally a good time for us to receive a lot of
new information. But because she says so,
we are attracted to next steps. We consider
the pros and cons and decide to take ourchance on the practice explained to us. The
doctor responsible for the study is called tothe hospital and a meticulous presentation
about the study and its risks versus benefits
is painted out for us. There are no risks in
our heads. Just a win. Now the problem
remaining is that the chance to hold ourboy right from the start is decided in the
toss of a coin.

If you have a story
to tell, a reflection
about your NIDCAP
experience or some poetry you havewritten inspired by NIDCAP thenplease send to the Editor.
John Eugene Buehler, Jr. ................ 18.

Trauma Informed.................................. 20.
Developmentally
Supportive Care
Science Desk ............................................ 23.
Reflections on the .............................. 25.
NIDCAP Trainers Meeting
NIDCAP Training Centers .............. 28.
Worldwide
Global Perspective-Ireland ........ 30.

NIDCAP on the Web ............................ 32.
NIDCAP Training Centers .............. 34.

(continued on p. 3)

DOI: 10.14434/do.v15i1.33773

developmentalobserver@nidcap.org
Endorsed by the NFI as foundations of NIDCAP education.

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2022 • Developmental Observer • 17

John Eugene Buehler, Jr., 1947-2021

I

n July of 2021, the NIDCAP Federation
International (NFI) lost a friend, a true
champion of our mission, and a generous
benefactor, John Eugene Buehler, Jr. Throughthe Buehler Family Foundation, John and hiswife Deborah, supported the NFI on a very
personal level for 20 years. John’s support ofhis wife’s work with premature infants grewquickly into a profound understanding andtrue appreciation of the NFI’s importance tothe international community of intensive care
professionals and the infants and families intheir care.
Giving was an integral part of John’s
personality and his life choices, and as the NFI
became a part of the fabric of the Buehler life,
support of its mission became a philanthropic
priority for them. John was a pillar of strength
behind Deborah’s efforts to advance theorganization and in particular to design theface of the NFI and advance its reach in theworld. John’s generosity touched many aspectsof the organization and is most recently andnotably apparent in our new website, launchedon the 20th anniversary of the NFI’s founding.

The new website was achieved with the solefinancial support of the Buehler family – a giftthat lives to further the reach of NIDCAP and will
do so for many years to come.
John was a caring, bright presence in theworld, a compassionately-minded individualfrom whom the NFI’s well-being has been
nurtured and sustained, and for which the NFI
is fortunate and grateful. For John Buehler, the
NIDCAP Federation International truly was alabor of love.
Please learn more about his presence in theworld through his obituary on the following page.
We thank John and Deborah, and theirchildren, Josh, Kate and Ian for their generous
contributions to the NIDCAP Federation
International and we extend our heartfelt
condolences to them for their loss.
As you read the Developmental Observer,
be reminded of John, who was a contributing
force behind the naming of the Developmental
Observer. John’s legacy of support lives on in
many ways, and the NFI and its members areforever thankful.
Gloria McAnulty and Sandra Kosta
DOI: 10.14434/do.v15i1.33790

18 • 2022 • Developmental ObserverObituary as published by The Boston Globe, August 13-15, 2021

John Eugene Buehler, Jr., known as Gene tohis family and college friends, died in Marin County,
California on July 25, 2021. He was born in Syracuse,
New York on December 3, 1947, the only child of John
Eugene Buehler, Sr. and Jane Mary Agnes Roe Buehler.
He is survived by his beloved wife of 32 years, Deborah
Moir Buehler of Mill Valley, California, his three children
Joshua D. Buehler, Kate R. Buehler and Ian P. Buehler,and his parents-in-law Joan P. Moir and Virgil P. Moir III.
After graduating from Christian Brothers Academy
in Syracuse, John attended Boston College as a freshmanin September 1965 and graduated in June of 1969. Soon
thereafter, he served in the US Navy as an Electronics
Technician, traveling the world and serving valiantly
during the Vietnam Conflict, while earning the National Defense Service Medal, Vietnam Service Medal, andVietnam Campaign Medal. John returned to Boston, his
adopted home. He earned his JD at Suffolk Law School
while serving as an editor on the Law Review. He later
did graduate work at The Georgetown Law Center. Aftera stint serving as a clerk for the Rhode Island Supreme
Court, he became an associate at Bingham, Dana &Gould LLP, working in the Investment Securities Department. He then took a position as Associate Counsel
in the Investment Law Division at the John Hancock
Mutual Life Insurance Company. In 1987, John moved
on to become the General Counsel and Chief Business
Development Officer at Energy Investors Fund Group in
Boston, a private equity firm dedicated exclusively to the
independent power and electric utility industry (the firstof its kind). He became a Co-Managing Partner. John’svision and leadership spearheaded the remarkable growthof the company, establishing it as a leader in the industry.
John always remembered his roots and the core values that his parents and his beloved Granny Roe instilledin him. John was exceptionally honored by his Boston
College affiliation and the friendships he made there. He
was enormously proud of serving as a two-term memberof the Boston College Board of Trustees. His business experience and love of his alma mater made him a valuable
and guiding member of the university’s governing body.
In addition, he was an extraordinarily generous benefactor to the school he so dearly loved. He and Deborah

endowed The Buehler Sesquicentennial Assistant Professorship for educator scientists at BC’s Lynch School of Education, supported BC’s Veterans Memorial in honor ofalumni who lost their lives serving in the military during
wartime, and funded the John E. Buehler, Jr. Family Athletic Scholarship Fund for starting pitchers on his beloved
BC baseball team in honor of his parents.
Many of his lifelong friends dated back to early days
spent living in Fenwick Hall at BC. If “Friendship is likethe Medicine of Life”, the friendships that John had area testament to that observation. John truly cherishedthe people in his life. His generous and engaging style ofentertaining was legendary. He particularly loved The Sea
Ranch in California where he was always happy hosting
gatherings with family and friends alike, making everyone
feel welcome. He was a BC football season ticket holder
for four decades and he was proud to commandeer a loyal
cadre of classmates, family and friends in their devoted
attendance at games at Alumni Stadium and beyond.
John’s journey was characterized by professional
achievements, lifelong friendships, and most especially,by his love and devotion to his adoring family. He wasexceedingly proud of the accomplishments of his wife
Deborah and his spirited and talented children. John
championed each member of his family in every way. He
supported Deborah’s work with the NIDCAP Federation
International, the nonprofit organization for prematureand ill newborns and infants and their families in hospitals. John was an enthusiastic supporter of Josh’s career
as fine dining chef, Kate’s passion for early elementary
school teaching, and Ian’s dedication to BC businessschooling and soccer playing. It was typical for John tobalance organizing his demanding professional travels
around his attendance at school, sports, restaurants, cultural and family events whether they were in California,
Massachusetts or somewhere in between. No occasionor conversation with John would be complete without his
inviting others to share in the love and pride he had for
his family.
John was effervescent, charismatic, yet humble. He
had the unique ability to make everyone in his presence
feel happy and welcome. He is greatly missed by everyone
who knew and loved him.

2022 • Developmental Observer • 19

Trauma Informed Developmentally Supportive Care
Kristy Fuller, OTR/L, CNT, CLC; Tara DeWolfe, DPT, CNT, CLC; Mary Coughlin BSN, RN, MS, NNP, RNC-E
Caring Essentials Collaborative, LLC Boston MA, USA

Introduction

Trauma informed developmentally supportive care createsa culture of care that focuses on the human experience. The
concept of trauma informed care was co-opted from the fieldof behavioral and mental health in 2013 for application in the
newborn intensive care unit (NICU). In essence, the concept
realizes the pervasiveness of trauma in everyday life, recognizes signs and symptoms of trauma, responds to trauma
through the adoption of evidence-informed best practices,and resists re-traumatization. Research across a wide range ofscientific fields as diverse as neuroscience, molecular biology,
epigenetics, developmental psychology, and psychoneuroimmunology verify intensive care hospitalization as a traumatic
life event for babies, families, and clinicians.1, 2 This experience
is associated with significant morbidity and mortality acrossphysiological, psychological, socioemotional, and spiritual
domains.1-6 Most recently, the American Academy of Pediatrics(AAP) has issued a policy statement summarizing the urgency
and requisite steps necessary to facilitate the integration of
trauma informed principles into all pediatric points of care.3“Trauma-informed care (TIC) in child health care operationalizes the biological evidence of toxic stress with the insights
of attachment and resilience to enhance healthcare delivery to
mitigate the effects of trauma”.3
What is trauma?

According to the Substance Abuse and Mental Health Services Administration, trauma results from an event, a seriesof events, or a set of circumstances that is experienced byan individual as physically and/or emotionally harmful orlife-threatening and has lasting adverse effects on the individual’s functioning as well as their mental, physical, social,emotional, and/or spiritual well-being.7 Within the context of
the NICU, infants experience trauma in big and small ways;
from life-threatening illness to the day-to-day experiences ofparental separation, fragmented sleep, a disruptive environment, painful experiences, stressful eating encounters, limited
mobility, prolonged time in bed, and so much more. Maternal
separation is the most significant trauma experienced by all
newborn mammals and preterm and/or critically ill newborns
are no exception to this reality. Morgan et al. discovered that
separation of mother and baby at two days of age for one hour
results in a 176% increase in autonomic activity and an 86%
reduction in quiet sleep with sleep cycling almost abolishedduring the separation period.8 In the NICU, the experience ofmaternal separation becomes the foundation for cumulative
toxic stress exposures that include unmanaged or underman20 • 2022 • Developmental Observer

DOI: 10.14434/ do . v 15 i 1.33788

aged stress and pain, sleep fragmentation, susceptibility toinappropriate sensory stimuli from the physical and social
environments, postural malalignment, and hazardous rituals
and routines that do not honor the personhood of the baby.9
The trauma experienced in this setting, however, is not limited
to the baby but encompasses the family’s experience as well as
the experience of the clinician who bears witness to the lived
trauma of both baby and family.
Why is trauma informed developmental care
important?

Adversity during childhood impacts the developmental trajectory of health and wellness across the lifespan.2 Individuals
who survive childhood adversity are at greater risk for cardiovascular disease, metabolic syndromes, generalized anxiety
disorders, depression, and other forms of psychopathology as
well as central sensitizing syndromes that encompass fibromyalgia, migraines, and irritable bowel syndrome to name afew.10 In a cohort study of more than six million individuals
with a birth history of varying degrees of prematurity there isa clear association of increased risk for premature adult deathassociated with non-communicable diseases; however, themost common cause of premature death in individuals born
premature is accidents and suicide.11
In addition to the trauma endured by the hospitalized baby,
the family experience of NICU hospitalization has been described as a traumatic event that shatters hopes, dreams, andexpectations for parenthood. Roque et al. report the significant
impact the NICU experience has on the emotional and mental
health of parents.12 Outcomes include an increased risk of depression, anxiety, and post-traumatic stress disorder for bothmothers and fathers because of their baby’s NICU hospitalization.12 Finally, research highlights the effect of bearing witness
to tragedy and trauma on clinicians’ physical, emotional, andspiritual health. Bearing witness is a “human-to-human way of
being-relating” to the truth of another’s experience.13 However,when clinicians are not aware of the dynamic nature of trauma
and trauma exposure it may limit their ability to interact inmeaningful and safe ways with patients and families while also
disrupting their personal wholeness.14
Why a trauma informed approach to care?

Trauma informed developmental care invites individuals tomove past procedure-driven routines, rituals, and practices; toshift from a dualistic perspective on healthcare to a wholistic
perspective. A trauma informed approach enables clinicians
to not only understand the biological implications of trauma,

Endorsed by the NIDCAP Federation
International, the National
Association of Neonatal Nurses, theCouncil of International Neonatal
Nurses and the National Associationof Perinatal Social Workers, theprogram combines online andvirtual/live education to support
clinicians in developing competence
across the eight attributes of theTrauma Informed Professional.
(Learn more: https://www.
caringessentials.net/).

but to then take the necessary actions to buffer the trauma
experience. Policies, protocols, and practices don’t transforman experience, people do. Exploring trauma informed care
begins with getting in touch with one’s own story. It is throughpersonal self-discovery that one can connect authentically withothers and begin the paradigm shift.

• Knowledgeable: Understanding core knowledge regarding
the science underpinning early life adversity and the biologic sequelae.

“In the process of creating transformation we ourselves are transformed” - Mary Coughlin• Personal wholeness: Developing habits to support physical,
psychological, social, spiritual, and existential well-being.

How to create transformation?

Personal transformation is the key to cultural transformation.
In the words of Carl Jung, “Your vision will become clear only
when you can look into your own heart. Who looks outside,
dreams, who looks inside, awakens”. (Carl Jung, Letters Vol 1 –1906-1950, p33, Princeton University Press, 1973). Becominga Trauma Informed Professional (TIP) is a journey of self-discovery and personal growth that awakens the individual totheir potentiality as a leader for change and a healer of hurtsthat too often go unnoticed in the highly technological worldof newborn intensive care. Eight attributes of the Trauma
Informed Professional have been established by an international, interdisciplinary faculty board of neonatal experts. These
attributes are:

• Healing intention: Fostering intention and presence, a cornerstone of trauma informed care, and based upon unitarycaring science theory.

• Courage: Taking courageous action to effect change,
increase self-actualization, and reduce moral distress by
respectfully challenging the status quo.
• Advocacy: Showing up for self and others by demonstrating respectful influence and inspiring excellence.
• Role model and mentor: Integrating the qualities of humility and empathy as a role model and mentor to inspireothers to greater success.
• Scholarly: Pursuing scholarship to consider all ways ofsharing information.
• Leader for change: Cultivating a respectful approach to leadership as a Trauma Informed Professional is transformational.

2022 • Developmental Observer • 21

Collaborative Caring

The aligned missions of Caring Essentials Collaborative andthe NIDCAP Federation International have led to collaborative teamwork aimed at transforming the experience of carefor babies, families, and clinicians in the NICU and beyond.
The complementary nature of NIDCAP Certification and theTrauma Informed Professional Certificate Program serves toadvance the competencies of the bedside clinician empowering these individuals to become confident leaders for change.
NIDCAP observers bear witness to the tiniest expressions ofsuffering, beyond what others can see. This depth of awarenesstakes a toll on the observer. Becoming a trauma informed
NIDCAP professional mitigates this impact on self and others.
Integrating trauma informed developmentally supportive carein the NICU and beyond changes not only individual lives
but society at large. Together, we can design the future of truly
compassionate healthcare.
References
1. Coughlin M. Transformative Nursing in the NICU: Trauma-informed Age-appropriate
Care. 2nd ed. New York: Springer Publishing Company; 2021
2. Shonkoff JP, Garner AS, Committee On Psychosocial Aspects Of Child And Family
Health, Committee On Early Childhood, Adoption, And Dependent Care, Section On
Developmental And Behavioral Pediatrics. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012 Jan; 129(1): e232-e246. doi:10.1542/peds.2011-2663.
3. Duffee J, Szilagyi M, Forkey H, Kelly ET, Council On Community Pediatrics, Council
On Foster Care, Adoption, And Kinship Care, Council On Child Abuse And Neglect,
Committee On Psychosocial Aspects Of Child And Family Health. Trauma-informedcare in child health systems. Pediatrics. 2021 Aug;148(2):e2021052579. DOI: https://doi.
org/10.1542/peds.2021-052579.
4. Forkey H, Szilagyi M., Kelly ET, Duffee J, Council On Foster Care, Adoption, And
Kinship Care, Council On Community Pediatrics, Council On Child Abuse And Neglect,
Committee On Psychosocial Aspects Of Child And Family Health. Trauma-informedcare. Pediatrics. 2021 Aug;148(2):e2021052580; DOI: https://doi.org/10.1542/peds.2021052580.

5.

6.
7.

8.
9.
10.
11.
12.
13.
14.

Montirosso R, Tronick E, Borgatti R. Promoting neuroprotective care in neonatal intensive care units and preterm infant development: Insights from the neonatal adequate carefor quality-of-life study. Child Development Perspectives. 2017 Nov;11(1):9–15. https://doi.org/10.1111/cdep.12208.
Sanders MR, Hall SL. Trauma-informed care in the newborn intensive care unit: promoting safety, security, and connectedness. Journal of Perinatology. 2018 Jan;38(1):3-10. doi:
10.1038/jp.2017.124.
Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept ofTrauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA)
14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration,
2014.
Morgan B E, Horn AR, Bergman N J. Should neonates sleep alone? Biol Psychiatry. 2011
Nov 1;70(9):817–825. https://doi.org/10.1016/j. biopsych.2011.06.018.
Weber A, Harrison TM. Reducing toxic stress in the NICU to improve infant
outcomes. Nurs Outlook. 2019 Mar-Apr;67(2):169–189. https://doi.org/10.1016/j.outlook.2018.11.002
Crump C. An overview of adult health outcomes after preterm birth. Early Hum Dev.
2020 Nov;150:105187. doi: 10.1016/j.earlhumdev.2020.105187.
Risnes K, Bilsteen JF, Brown P, Pulakka A, Anderson A-MN, Opdahl, S., et al. Mortality
among young adults born preterm and early term in 4 Nordic nations. JAMA Netw Open2021 Jan 4;4(1):e2032779. doi: 10.1001/jamanetworkopen.2020.32779.
Roque ATF, Lasiuk GC, Radunz V, Hegadoren, K. Scoping review of the mental
health of parents of infants in the NICU. J Obstet Gynecol Neonatal Nurs. 2017 JulAug;46(4):576-587. doi: 10.1016/j.jogn.2017.02.005.
Naef R. Bearing witness: a moral way of engaging in the nurse-person relationship. Nurs
Philos. 2006 Jul;7(3):146-156. DOI: 10.1111/j.1466- 769X.2006.00271.x
Missouridou E. Secondary posttraumatic stress and nurses’ emotional responses
to patient’s trauma. J Trauma Nurs. 2017 Mar/Apr;24(2):110-115. DOI: 10.1097/
JTN.0000000000000274.

NIDCAP

Care in the Moment

Co-regulation during caregiving tasks

22 • 2022 • Developmental Observer

SCIENCE DESKThe Importance of Doing Dual DiligenceJeffrey R. Alberts, PhD
Indiana University, NFI Science Committee, Associate Editor for Science

DOI: 10.14434/do.v15i1.33787

Target Article: Maryam Fatollahzade, Soroor Parvizy, Mandana Kashaki, Hamid Haghani & Mona Alinejad-Naeini (2020) The effect of gentle humantouch during endotracheal suctioning on procedural pain response in preterm infant admitted to neonatal intensive care units: a randomized
controlled crossover study, The Journal of Maternal-Fetal & Neonatal Medicine.

Little is ordinary about an ordinary
day in a NICU. Without a break,
24/7, technological and biomedical wizardry is combined with expert
applications of other, “low-tech” tools
and “no-tech” methods. Together, itworks: Babies born as early as 23- or
24-weeks survive and thrive. Miraculous outcome is almost ordinary. How
do these miracles happen?
Let’s start with one element in the
miracle-making formula: The element is human touch. No technology
needed. Our target article, a recent
study by Fatollahzade1 was designed
to ask whether an intervention termed
Gentle Human Touch (GHT) would
reduce pain during the suctioning
procedure commonly needed to keep
open the airways of premature infants
equipped with an endotracheal tube.
34 preterm infants (born at 2734wks) comprised the study population. Cleverly, this research teamutilized the on-going care regime asa testbed, knowing that the suctioning
procedure, vital to breathing supportof the intubated neonate is potentiallypainful. Their “crossover” design refers
to an efficient and statistically powerful approach in which each baby
is tested with and without the experimental intervention. Order was counterbalanced, meaning half the babies
received the GHT intervention duringsuctioning on the first trial and routine
treatment (no intervention) during thenext need-based suctioning. The otherbabies also experienced both conditions, but in the reverse order.

The GHT intervention was administered to infants positioned prone in agently flexed posture. The researcher
cupped one hand around the infant’shead while cupping the other handaround the infant’s bottom. GHT wasprovided for the duration of the suctioning procedure. Using the Premature Infant Pain Profile (PIPP) protocol,
a 15-sec-long pre-suction baseline
assessment was made, followed by a30-sec-long post-suctioning assessment. The PIPP yields a numerical score
of infant pain in three ranges (mild tosevere). It is considered well-validated
and is used widely in research.2
The results were impressive. With
standard care, 85% of the infants
showed moderate pain responses tothe suctioning procedure. GHT reduced the occurrence of moderate
pain responses to 65%. Severe pain
responses were manifested in about
9% of the control trials and GHT reduced these to about 3%. Such results
are a first step toward adding Gentle
Human Touch to the list of non-pharmacological methods of pain management in the NICU. Many of us areaware of the powers of skin-to-skincontact (Kangaroo Maternal Care3,4)
as well as the efficacy of holding5, facilitated tucking,6-8 nursing,9 non-nutritive sucking,10 and oral sucrose,11, 12 eacha method for pain mitigation, andmore. Our target article is a new contribution. It builds on past knowledgeof GHT and touch; it newly addresses
the procedural pain of suctioning;
and it expands the range of PIPP for

assessment. There is more to learn
about the scope, the magnitude, andunexplored outcomes of using GHT.
Though preliminary in several
ways, Fatollahzade et al.1 is an elegant
study, particularly when viewed in thelight of basic biomedical ethics. Importantly, they noted that GHT is safe.
It did no harm. By explicitly registeringthat no harm to the baby came fromthe procedure, they formally recognized a vital dimension of their method. In other words, they addressed thefamiliar dictum, Primum non nocere,or ‘First, do no harm’.
But, it is not enough to deem
something as ethically-sound because risk is minimal. There is an
ethical imperative to examine whether
procedure actually “does good”? 13 In
fact, Fatollahzade and her colleagues
reported that GHT reduced pain responses. Gentle Human Touch duringsuctioning provided actual, active
benefit.
Stay with me now: “Not to harm”,
in the language of ethics is non-maleficence [mə-‘le-fə-sən(t)s]. The
principle of non-maleficence is alive
and well throughout medical ethics.
After all, Premum non nocere. Infants
cared for in the NICU deserve pledges
of non-maleficence. All our patientsdo. But, again, it is not enough simply to avoid doing harm. In addition,
ethical practices demand that we
promote and do good. “To do good” inthe language of ethics is beneficence[bə-‘ne-fə-sən(t)s]. A beautiful word
for a beautiful principle.

2022 • Developmental Observer • 23

Whereas non-maleficence ismainly a prohibition against harm,beneficence has at least three forms,
each of which we should examine aspart of our awareness of doing good.
As such, beneficence includes (a.)
doing good, (b.) preventing harm, and(c.) removing harm.
In the NICU we can say the coin of
the realm is ethical treatment of eachbaby. There are two sides to this coin:non-maleficence and beneficence.
As two sides of the same coin, they
are inseparable. So, as we hold thiscoin in our hand, we must continuallyturn it and examine each side. Such
diligence is due to both sides. For
this reason, I favor the label of dual
diligence, stipulating the obligation tohonor both principles – beneficenceand non-maleficence.
Illustrative examples of nonmaleficence without beneficenceabound. Look no further than theprevious issue of the Developmental Observer!14 Dr. Ita Litmanovitz, aneonatologist and NIDCAP Trainer,
contributed a thoughtful and expert
Commentary to the Science Deskcolumn. Ita examined a technological tour de force report,15 in which
extremely prematurely born neonates
were monitored for their first 72 hours
with a combination of cerebral regional oxygen saturation (CrSO2) via Near
Infrared Spectroscopy (NIRS), amplitude-integrated EEG (aEEG), functional
echocardiography (ECHO), further
supported by head ultrasounds. The
authors concluded that such multimodal monitoring “is feasible, safe, andwell tolerated by extremely prematurely
born infants in the first 72 h after birth”.
True, yes, but remember dual diligence!
Dr. Litmanovitz’s commentary
guides us through a set of criticalconsiderations of the ocean of datathat were collected -- without harming the newborns’ skin or increasing
adverse events. Despite the investigators’ rationale, the multimodal mea24 • 2022 • Developmental Observersures did not prevent IVH or reduce
adverse outcomes. More serious, however, was that to make these measurements, there was an obligatory,
72-hr separation of infant and mother!
It is well-documented that suchseparations can have both immediate and long-term negative effects
both on the baby and mother. Dr.
Litmanovitz cited of the costs of losing
early postnatal mother-infant contact, while seeking some still-elusive
benefits of predicting a hemorrhagic
event. Awareness and attendance todual diligence – recognizing and documenting both non-maleficence andbeneficence can provide the clarity
we need to realize ethical care.
Dual diligence is not only fullycompatible with NIDCAP practice, it isembedded within it.
In caregiving, in formulating
treatment protocols, and in evaluating
research, it is imperative for us to examine both avoiding harm and doing
good. Doing dual diligence is a foundation of ethically-guided practice.
NICU miracles of successful development arise from a combination ofhigh-tech, low-tech and no-tech. We
do not know how they combine into
success, but we do know that they are
all involved, and I bet that it is not via
simple addition of separate factors.
Each modality supports the other.
High-tech medical wizardry is crucial.
So is parental love and human touch.
Remember always that an ordinary day in a NICU is made of theextra-ordinary. Ordinarie in Old French,
for rule or ordinance, as in rules thatprescribe forms of action, gave us
the English word ordinary. Think of
the protocols you follow that makean ordinary day. In this way, everything you do makes miracles almost
ordinary. Look for and see the dualityof non-maleficence and beneficencepresent in a simple protocol. In developmental care, they are the core of
the miraculous.

References
1. Fatollahzade M, Parvizy S, Kashaki M, Haghani H,
Alinejad-Naeini M. (2020) The effect of gentle humantouch during endotracheal suctioning on proceduralpain response in preterm infant admitted to neonatal
intensive care units: A randomized controlled crossoverstudy, The Journal of Maternal-Fetal & Neonatal Medicine, DOI: 10.1080/14767058.2020.1755649
2. Stevens BJ, Gibbins S, Yamada J, et al. (2014) The
premature infant pain profile-revised (PIPP-R): initial
validation and feasibility. Clinical Journal of Pain,30(3):238–243. DOI: 10.1097/AJP.0b013e3182906aed
3. Mosayebi Z, Javidpour M, Rahmati M, et al. (2014) The
effect of kangaroo mother care on pain from heel lance
in preterm newborns admitted to neonatal intensive
care unit: a crossover randomized clinical trial. Journalof Comprehensive Pediatrics, 5(4):1–6. DOI : 10.17795/
compreped-22214
4. Johnston C, Campbell-Yeo M, Disher T, Benoit B,
Fernandes A, Steiner D, Inglis D, Zee, R. (2017) Skinto-skin care for procedural pain in neonates, Cochrane
Database Systematic Reviews, 2 (2): CD008435. doi:
10.1002/14651858
5. Riddell RRP, Racine NM, Gennis HG, Turcotte K,
Uman LS, Horton RE, Kohut SA, Stuart JH, Stevens B,
Lisi DM. (2015) Non-pharmacological management of
infant and young child procedural pain. Cochrane Database of Systematic Reviews, doi.org/10.1002/14651858.
CD006275.pub3
6. Axelin A, Salantera S, Lehtonen L. (2006) ‘Facilitatedtucking by parents’ in pain management of preterm
infants— a randomized crossover trial. Early Human
Development, 82(4):241–247. doi.org/10.1016/
7. Alinejad-Naeini M, Mohagheghi P, Peyrovi H. (2014)
The effect of facilitated tucking during endotracheal
suctioning on procedural pain in preterm neonates: arandomized controlled crossover study. Global Journalof Health Sciences, 6(4):278-284. doi: 10.5539/gjhs.
v6n4p278
8. Obeidat H, Kahalaf I, Callister LC, et al. (2009) Use of
facilitated tucking for nonpharmacological pain management in preterm infants: A systematic review. The
Journal of Perinatal and Neonatal Nursing, 23(4):372–
377. doi: 10.1097/JPN.0b013e3181bdcf7
9. Shah PS, Herbozo C, Aliwalas LL, Shah VS. (2012)
Breastfeeding or breast milk for procedural pain inneonates. Cochrane Database of Systematic Reviews, 12:CD004950.
10. Vu-Ngoc H, et al, & Duong PDT. (2020) Analgesic effectof non-nutritive sucking in term neonates: A randomized control trial. Pediatrics and Neonatology, 61 (1):106-113. doi: org/10.1016/j.pedneo.2019.07.003
11. Blass E, Watt L. (1999) Suckling- and sucrose-induced
analgesia in human newborns, Pain, 83(6): 611. doi.
org/10.1016/S0304-3959(99)00166-9
12. Kassab M, Anabrees J, Harrison D, Khriesat W, Chen S.
(2017), Sweet taste drinks effects on reducing injection
pain and associated stress among infants: A meta-analysis of randomized controlled trials. Open Journal of
Pediartrics and Neonatology, 1(1): 1-12.
13. Beauchamp TL & Childress JF. ( 2013), Principles ofBiomedical Ethics, Seventh Ed., New York: Oxford
University Press.
14. Litmanovitz I., (2021) Combined multimodal cerebral
monitoring and focused hemodynamic assessment in
extremely low birth weight infants – Potential benefits
or potential costs? Developmental Observer, 14(2): 1820. DOI: 10.14434/do.v14i2.33001
15. Deshpande P, Jain Ríos DR, Bhattacharya S, Dirks J,
Baczynski M, McNamara KP, Hahn C, McNamara
PJ, Shah P, Guerguerianb AM. (2020) Combined
multimodal cerebral monitoring and focused hemodynamic assessment in the first 72 h in extremely low
gestational age infants. Neonatology, 117:504–512. DOI:
10.1159/000508961

NIDCAP TRAINERS MEETING 2021

Reflections on the Virtual 32nd NIDCAP Trainers
Meeting 20 – 22 October 2021
Attendance at a NIDCAP Trainers Meeting provides us with the opportunity to hear new
ideas and learn from our colleagues. Below we have three unique perspectives of themeeting from Members of the NFI.

DOI: 10.14434/do.v15i1.33789

Jacques Sizun, MD

Jim Helm, PhD

Centre Hospitalier Universitaire de Toulouse| CHU Toulouse
Service de Néonatologie

Director Emeritus, Carolina NIDCAP Training Center

During the 32nd Annual NIDCAP trainers Meeting, Sari Goldstein Ferber, PhD, from Bar Ilan University, Israel, presented aninteresting reflection on the potential impact of NIDCAP on
the homeostatic regulation of hypothalamic (HPA) axes. She
presented three axes that are regulated by melatonin, cortisoland oxytocin. They play important roles in the maturationof circadian rhythms, the modulation of stress, and the relationship and bonding. The behavioral observations using the
Synactive Theory framework are focused on the managementof the wake/sleep states, and on the permanent balance (andimbalance) of the stress-induced behaviors. The baby’s strategies for self-regulation and the co-regulation by parents areimportant to manage stress behaviors. Recommendations arealways oriented toward attachment and bonding support.
This presentation could have three impacts:• The first impact is on my own vision of the newborn, theirdevelopment and care. It is very important not to stay inour “ivory tower”, being too comfortable and secure canisolate us from the outside world. Confronting our own
theoretical models with advances in science and medicine
is an exercise that is sometimes intellectually difficult butvery nurturing.
• The second impact concerns our healthcare professional colleagues who may not be convinced by our approach to care.
The psychoneuroendocrine perspective can be a gateway to
NIDCAP for them, as it has been observed for other fieldsof newborn care such as: pain (close link between developmental care practices and non-pharmacological treatments);
palliative care (same philosophy of holistic, individualized,
family-centered care); and/or breastfeeding support.
• The third impact could be for research. Using tools fromother fields of clinical research to explore the impact of
NIDCAP appears exciting.
Conclusion: Connection is essential!

When I attend a conference, and in particular, the NIDCAP
Trainers Meeting, I hope to be re-energized around themission and goals of the NIDCAP approach and… to see
old friends who have shared goals; to learn about new ideas,
research and applications; and to be inspired. This day did notdisappoint me, rather it brought energy, reflection and thehard-to-come-by inspiration.
The Pearls of Wisdom segments of the meeting havemembers sharing personal experiences that have helped shape
their caring and offer participants a unique opportunity to joina colleague’s personal perspective. Andrea Nykipilo, RN andgretchen Lawhon, PhD, RN, FAAN provided a wonderful start
to the day with thoughts on how the NIDCAP approach has
opened one to be in the moment and how learning imparts asense of duty to teach others. Perfect for NIDCAP work.
Dr Als’ keynote address built from that setting-of-thestage as she embraced the meeting’s theme – Always Together– and examined it from within the uncertainties and cautiousness of the pandemic. Discussing the critical importance of“being together” during critical times, whether during a pandemic or negotiating the challenges of being admitted to an
NICU. No matter, human togetherness is supportive, facilitates
growth, development and healing and especially for the fragile
infants and traumatized families of the NICU.
The NFI Membership Meeting, presided over by Deborah
Buehler, PhD, President of the NFI Board of Directors also hadsuch a positive vibe as examples of the many pockets of growth
were provided where the NIDCAP approach is understood,
valued, and promoted. NFI members need to find and read thecommittee reports. In our daily lives we can easily lose the “bigpicture” of growth around the world. This meeting helps us
reconnect.
Clinical Practice and Abstract presentations showedstrong examples of affecting change in systematic ways be ita specific care practice (Four-handed care: L. Eitan) or a unit
culture shift as we saw in the beautiful photo presentation from
Sweden (Continuous skin-to-skin contact: S Klemming). The

2022 • Developmental Observer • 25

NIDCAP TRAINERS MEETING 2021

Some of the 124 attendees from 23 countries present for the Virtual NIDCAP Trainers Meeting.

abstracts featured efforts to support families in their challenge
to parent in the NICU and as NICU supports are removed,
through the transition to home.
The Journal Club, a fairly new component of meetings
that has taken hold, brings us new ideas. This segment gave us
two articles to share and discuss. Generation Z, as with each
new family, will challenge us to accept families, individuals, as
they are, and adapt. The bio-ecology of behavior and behavior
change offers new insights as to how we understand change
and perhaps a way to measure differences in change.
A day full of thoughtful perspectives on change. May theyinspire and challenge our next year as we work together.
Mandy DalyNFI Board Member, Founder of the Irish Neonatal HealthAlliance
Preterm birth flips the paradigm of parenthood on its axis
and robs families of their hopes, dreams and expectations. A
preterm birth is often preceded by a rocky and tumultuous
pregnancy journey and can culminate in an emergency birthsituation that is fraught with urgency, fear and uncertainty. A
26 • 2022 • Developmental Observer

full-term healthy pregnancy, a natural birth, those precious
first moments when Mum meets baby, babies first outside of
the womb sensory experience skin to skin with Mum, hearing her voice and smelling her scent are replaced by clinicalhandling by strangers, pain as airways are cleared and lines
inserted, and fear and confusion.
When a newborn requires care in the Neonatal Unit
families are forced to re-evaluate their anticipated parentingrole and as if being separated from one’s baby at birth is nottraumatic enough, families are burdened further by having tolearn the language of the neonatal unit, shelve their own needto recover physically and emotionally from the traumas of thepregnancy and delivery and find a way to parent their sick andvulnerable infant in an environment that excels at erecting
barriers.
Research has demonstrated that the relationship that ababy has with their parent or primary carer, has an enormous
impact on their future mental, physical, social, and emotional
health. The neonatal period is critical to the development of
the parent-child relationship. In fact, the strength of this relationship is the main predictor of how well a child will do bothin school and in life. It is not founded on the quality of the care

NIDCAP TRAINERS MEETING 2021

or parental love, but on the non-verbal emotional communication that a parent develops with their child, known as theattachment bond.
Experience shapes the brain and having an infant in the
neonatal unit has the potential to erode the fundamental andfoundational natural connections; the consequences of which,
if unaddressed can be detrimental for the infant and the family
unit. Families are the cornerstone upon which newborn caremust be developed and delivered. It is imperative that newborncare practices embody the essence of connecting families andstrive to repair the fractured connections at every juncture. The
NIDCAP approach to care acknowledges the important rolethat families play in their baby’s development, it recognizes theinfant’s need for positive familial and sensory experiences tosupport his/her developing competencies and it facilitates connections at every step of the journey by protecting the developing infant brain and the evolving infant parent relationship.
The COVID-19 global pandemic has brought unimaginable
challenges for newborn healthcare systems and families, butnever has it been more important to remain steadfast in keeping
babies and their families together. On the first day of the NFITrainers Meeting, Dr. Manuela Filippa’s presentation about her
unit’s family-based intervention that focuses on the benefits ofearly vocal contact between parents and preterm infants, struck
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a chord close to my heart. Having spent over three months in aneonatal unit with my daughter many years ago, at a time when
parents were still considered “visitors” on the unit, and seeing 15
years of advocating for family and infant centered developmentally supportive care to be embedded at the heart of care pathways, wiped out over-night in many NICUs around the worldby the pandemic, it was encouraging to see the positive resultsfrom initiatives such as Manuela’s. We need to see more neonatal
units adapt their practices to reflect positive research findings
and researchers need to explore more opportunities that embedfamilies at the heart of neonatal care.

“Always Together
Makes All The Difference
For All Involved”—Dr. Heidelise Als, Founder of the
NIDCAP Federation International(Continued from p. 11)
References:
1. Graven SN, Browne J V. Sensory development in the fetus, neonate, and infant: Introduction and overview. Newborn Infant Nurs Rev 2008; 8: 169–172. DOI:10.1053/J.
NAINR.2008.10.007
2. Bieleninik Ł, Ghetti C, Gold C. Music therapy for preterm infants and their parents: A
meta-analysis. Pediatrics 2016; 138 (8): e20160971. doi: 10.1542/peds.2016-0971
3. Arnon S, Diamant C, Bauer S, et al. Maternal singing during kangaroo care led toautonomic stability in preterm infants and reduced maternal anxiety. Acta Paediatr Int J
Paediatr 2014; 103: 1039–1044. doi: 10.1111/apa.12744
4. Haslbeck, Friederike; Hugoson, Pernilla (2017). Sounding Together: Family-CenteredMusic Therapy as Facilitator for Parental Singing During Skin-to-Skin Contact. In: Filippa,
Manuela; Kuhn, Pierre; Westrup, Björn. Early vocal contact and preterm infant brain
development: bridging the gaps between research and practice. Cham: Springer, 217-238.
doi.org/10.1007/978-3-319-65077-7_13
5. Cresswell JW. Research Design – Qualitative, Quantitative and Mixed Methods. 3rd
Edition. 2009. Sage Publications, Los Angeles. https://www.ucg.ac.me/skladiste/blog_609332/objava_105202/fajlovi/Creswell.pdf
6. Loewy J, Stewart K, Dassler A-M, et al. The Effects of Music Therapy on Vital Signs,
Feeding, and Sleep in Premature Infants. Pediatrics 2013; 131: 902 LP – 918. doi: 10.1542/
peds.2012-1367
7. Longin E, Gerstner T, Schaible T, et al. Maturation of the autonomic nervous system: differences in heart rate variability in premature vs. term infants. J Perinat Med,
2006;34(4):303-8.doi: 10.1515/JPM.2006.058
8. Westrup B. Newborn Individualized Developmental Care and Assessment Program(NIDCAP) - Family-centered developmentally supportive care. Early Hum Dev 2007; 83:
443–449. doi: 10.1016/j.earlhumdev.2007.03.006

2022 • Developmental Observer • 27

NIDCAP TRAINING CENTERS WORLDWIDE

DOI: 10.14434/do.v13i2.31062

We welcome four new Training Centers to theever growing list
UZ Leuven NIDCAP Training Center
Leuven, Belgium

Director: Anne Debeer, MD, PhD

Co-Director: Chris Vanhole, MD, PhD

NIDCAP Trainers: Bieke Bollen, PhD & Kelly Janssens, RN
Contact: An Carmen

Email: nidcaptrainingcenter@uzleuven.be

Japan National NIDCAP
Training Center

Seirei Christopher University, Shizuoka, Japan
Director: Tomohisa Fujimoto, PT

Co-Directors: Kanako Uchiumi, RN, MW, Noriko
Moriguchi, MSN, RN, PHN, IBCLC & Yoko Otake, RN
NIDCAP Trainer:Tomohisa Fujimoto, PT

NIDCAP Trainers in Training: Kanako Uchiumi, RN,
MW, Noriko Moriguchi, MSN, RN, PHN, IBCLC & Yoko
Otake, RN
Contact: Tomohisa Fujimoto, PT
Email: fusan.mail@gmail.com

28 • 2022 • Developmental Observer

Lund-Malmö NIDCAP Training andResearch Center, Sweden
Skane University Hospital, Malmö, Sweden
Director: Elisabeth Olhager, MD, PhD

Co-Director and contact: Stina Klemming, MD
Email: nidcap.sus@skane.se
Trainer: Stina Klemming, MD

Trainer-in-training: Pernilla Stenman, RN
Nursing Director: Jessica Jubner, RN

Medical Director: Kristbjörg Sveinsdottir, MD

Psychologist: Johanna Månsson, PsyD, PhD, NBOprofessional

Board members: Emelie Oscarsson, Christina Schilow
Sandell, Kristina Albrecht
Together, the two hospitals, Lund and Malmö, serve a region of 15500 births every year and care for 1050 infants(6.8% of infants born) in their two NICUs. Lund-Malmö NIDCAP Training and Research Center has been open andactive since October 1st, 2021 and will have its formal inauguration during the 2022 Conference on Ultra-Early
Intervention, March 24th - in Lund and online in a hybrid format.

Sant Joan de Déu Barcelona NIDCAP
Trainer Center
Barcelona, Spain

Director: Ana Riverola, MD
NIDCAP Trainer: Ana Riverola, MD
Medical Director: Martín Iriondo Sanz, MD, Chief of
Neonatal Service
Nursing Director: María José Troyano Martos, RN,
NIDCAP Professional
Contact: Ana Riverola
Email: ariverola@hsjdbcn.org

MissionThe NFI promotes the advancement of the philosophy and science of NIDCAP
care and assuresth e quality of NIDCAP education, training, mentoring andcertification for professionals, and hospital systems.
Adopted by the NFI Board, July 1, 2019

VisionThe NFI envisions a global society in which all hospitalized newborns and theirfamilies receive care in the evidence-based NIDCAP model. NIDCAP supports
development, enhances strengths and minimizes stress for infants, family
and staff who care for them. It is individualized and uses a relationshipbased, family-integrated approach that yields measurable outcomes.
Adopted by the NFI Board, October 20, 20172022 • Developmental Observer • 29

Global Perspective on
Developmental Care - Ireland
Susan Vaughan1 and Mary O’Connor2
1

Cork University Maternity hospital,2 Coombe Women & Infants’ University Hospital, Dublin.

Ireland is an island country in north-western Europe,comprising the Republic of Ireland, and Northern Irelandwhich is part of the United Kingdom. The population of
the Republic of Ireland is approximately five million. The publically funded healthcare system in Ireland provides healthcare
and personal social services. The hospital structure is organised into seven groups, four of whom have tertiary centres. The
nineteen neonatal units are classified according to their number of births into local, regional and tertiary neonatal units.
There are 11 local units, four regional units and four tertiary
units. There are 300 neonatal cots in total: 193 special care, 52high dependency care and 55 intensive care. Three of the four
tertiary Level 3 Neonatal Units are situated in Dublin city andone in Cork city: Cork University Maternity hospital.
A new model of care for neonatal services in Ireland waslaunched in 2015. The recommendations set out in this model
were benchmarked against international standards and havebeen informed by neonatologists, paediatricians, neonatal nurses and health and social care professionals (HSCPs) involved inproviding care to newborn babies. There was also consultation
with the key stakeholders: parents whose babies had received
care in a neonatal unit, through our partners the Irish Neonatal
Health Alliance and the Irish Premature Babies Association. The
views of all groups were considered in the development of the
new model, with the overall aim of designing systems that will
provide quality evidence-based care to every baby. The reportstated that, “It is a goal in NICUs to provide family-centredcare, aided by programmes such as the Newborn Individualized

30 • 2022 • Developmental Observer

Developmental Care and Assessment Programme (NIDCAP)
which aims to provide individual holistic care to infants in anenvironment that can be potentially toxic to the developing
brain”. Currently, limited numbers of nurses have been NIDCAP
trained. A CNS role specialising in family-centred care and
NIDCAP will be established, initially in the tertiary units with
future expansion to other units. Developmental care is the namethat encapsulates NIDCAP, FINE and FiCare in Ireland. Someunits are adapting aspects of FiCare while others are working
with the FINE programme.
Cork University Maternity hospital (CUMH)
was opened in 2007,
formed by the amalgamation of services of threematernity hospitals in
Cork city. CUMH is oneof the busiest units inthe country with 7,500 births yearly with 1 in 10 babies admitted to the Neonatal Unit (NNU). CUMH, forms part of the
Health Service Executive South/South West hospital groups, theNeonatal Unit at CUMH is a referral centre for extreme preterm
and ill babies from counties Kerry, Tipperary, Waterford andLimerick Maternity units. The NNU in CUMH is a 50 bed unit,
made up of 18 intensive care beds and 32 special care/immediatecare beds. Newborns from 23 weeks gestation to term are looked
after in the unit, from admission to discharge. It is also the regional centre for newborns needing therapeutic cooling.

Developmental care was first introduced into Cork by Inga
Warren with lectures to staff in 1990 but it wasn’t until 2007
that Professor Anthony Ryan (neonatologist) and Lucille Bradfield (neonatal nurse manager) secured funding for formal
NIDCAP training to begin. In 2009, two neonatal nurse/midwives, Susan Vaughan and Ann Flynn were certified under theguidance and training of Dr. Nikk Conneman and Monique
Oude Reimer. In 2011/2012 three more nurses, Ann Buckley, Kathleen O’ Riordan and Mary Cullinane and Annmarie
Cronin, NNU physiotherapist, became NIDCAP professionals.
In CUMH, a multidisciplinary group was set up including pastparents of the unit, social work, OT, SLT, medical and nursing
staff and the NIDCAP Professionals to develop a more family-centered unit and to promote developmental care. We are
striving as a unit to become not just family centred but family
integrated. Some of our recommendations and changes to theunit are: welcome booklets for parents, in-service study days
for all staff members in the unit, ownership to the promotionof developmental supportive environment and care to all staff,
a read-a-thon to encourage parents to read and speak to theirbabies now and in the future. We developed Kangaroo/skin toskin care protocols, guidelines and education days and werevery proud that KC was such a normal and highly valued partof our care of newborns that it was not stopped or time limited
to mothers during the recent pandemic. The NIDCAP groupin CUMH is responsible for the education sessions in Developmental Care in the Higher Diploma Neonatology Nursing
at University College Cork (UCC), new medical doctors to the
NNU, and student nurses and midwives within CUMH. We
have celebrated World Prematurity Day on November 17th forthe last 10 years, combined with a coffee morning for all pastpatients and their parents. We are very lucky to have the presence and support of Mandy Daly and the Neonatal Health Alliance at the coffee morning and throughout the year. CUMH isalso a research hospital and is linked to INFANT, Irish Centre
for Maternal and Child Health Research. The NIDCAP teamare currently involved in research projects within the unit.
There are plans to develop nurse specialists roles in Developmental Care within the unit.
The Coombe
hospital in Dublin was
founded in 1826 due toextensive maternal andinfant mortality in theenvirons and relocatedin 1967 to the current
site. The hospital, oneof the three stand-alone maternity hospitals in the Irish setting
has undergone several revisions of title and is presently known
as the Coombe Women & Infants’ University Hospital (CWIUH). After much discussion on location, it will be the maternity hospital that will be co-located with St James’s Hospital andthe National Children’s Hospital which is currently under con-struction. We work closely with our Level one partner within
the Dublin Midlands Hospital Group. Our neonatal centre
has a forty-cot capacity, 14 intensive care, 10 high dependency
care and 16 special care cots. We are one of the three Dublin hospitals that facilitate the National Neonatal Transport
programme on a three-week rotation. We are also the national cardiac referral centre including referrals from Northern
Ireland for delivery and stabilisation before transferring to
the Children’s Heart Centre. At local level we have introduced
several family centred developmental care initiatives, which include increasing parental presence, encouraging their presence
on ward rounds, and increased participation in their baby’scare. There is very positive feedback from the read-a-thon. We
have reinvigorated our parents support group, ‘Parents’ TimeOut ‘(PTO), facilitated by an interdisciplinary team including
psychologist, neonatal nursing, and allied health professionals
again with positive feedback. COVID-19 really interfered with
our philosophy as infection control measures took precedent
during the pandemic, yet we collaborated with parents andwhile we restricted both parents being present together, we
did not restrict/limit their time with their baby. We introduced
face-time for baby and families which was a great success.
Continued professional development is central to our
ethos in CWIUH and we facilitate family centred developmental education sessions for the Foundation Levels I and II in
Neonatal Nursing which is affiliated to Trinity Collage Dublin,
Postgraduate Diploma in Neonatal Intensive Care Nursing
which is affiliated with the Royal College of Surgeons (Ireland)and both Foundation and Postgraduate Diploma level in Paediatric Intensive Care Nursing affiliated to University College
Dublin.
CWIUH is the Irish FINE hub and we work closely with
Inga Warren, who facilitated NIDCAP training in our unit.
Presently we have one NIDCAP Professional, however formal
NIDCAP observations and write-ups are not performed at the
moment. This will change once we appoint the Clinical Nurse
Specialist in Family Centred Developmental Care. Our second
NIDCAP Professional immigrated to the Middle East. Ourclose association with Inga Warren continues in facilitating
all FINE programmes and we have collaborated with the teamfrom CUMH for FINE level I. We have coordinated FINE Level I on an annual basis since 2014, serving neonatal, paediatricnurses and allied health professionals and have worked with
Inga in facilitating FINE level I online, our first in the autumn.
Since 2018 FINE Level I became mandatory for all nursing
staff in our unit, health care assistants and our allied healthcolleagues also participate. Five neonatal nurses and a physiotherapist have completed FINE Level II.
It is clear that there is still considerable development needed in family centred developmental care in Ireland, a challengethat we are rising to meet.
DOI: 10.14434/do.v15i1.33786

2022 • Developmental Observer • 31

NIDCAP ON THE WEB

NIDCAP Training Centers – Facebook Pages
During the past six months, despite the adversity facing the NIDCAP Training Centers and NIDCAP Professionals
worldwide, many positive achievements have taken place. This series of snapshots from the various Training
Centers enable us to all celebrate and acknowledge each other’s achievements.

NIDCAP BLOG

32 • 2022 • Developmental Observer

NIDCAP.org

NIDCAP ON THE WEB

The NFI NIDCAP Blog offers observations

from many different perspectives on NIDCAP and
its implementation, such as NIDCAP and APIB

training, Nursery Certification, the science behind

the approach, the family experience with NIDCAP,

the NFI, and much more. We encourage you to visit
the NIDCAP Blog and to leave comments for our

bloggers and our NIDCAP community in general.

If interested in becoming a guest blogger pleasecontact Sandra Kosta at sandra.kosta@nidcap.org.

NIDCAP BLOG

NIDCAP.org

2022 • Developmental Observer • 33

NIDCAP TRAINING CENTERS

AMERICAS

North America

CANADA

Edmonton NIDCAP Training Centre
Stollery Children’s Hospital
Royal Alexandra Site
Edmonton, AB, Canada
Co-Directors: Andrea Nykipilo, RN and
Juzer Tyebkhan, MB
Contact: Juzer Tyebkhan, MB
email: Juzer.Tyebkhan@ahs.ca

UNITED STATES

St. Joseph’s Hospital NIDCAP Training Center
St. Joseph’s Hospital and Medical Center Phoenix,
Arizona, USA
Co-Directors: Bonni Moyer, MSPT and
Marla Wood, RN, BSN, MEd
Contact: Annette Villaverde
email: Annette.Villaverde@commonspirit.org
West Coast NIDCAP and APIB Training Center
University of California San Francisco San Francisco,California, USA
Director and Contact: Deborah Buehler, PhD
email: dmb@dmbuehler.com
Children’s Hospital of University of Illinois (CHUI) NIDCAP
Training Center
University of Illinois Medical Center at Chicago
Chicago, Illinois, USA
Co-Directors: Doreen Norris-Stojak MS, BSN, RN, NEA-BC &Jean Powlesland, RNC, MS
Contact: Jean Powlesland, RNC, MS
email: jpowlesl@uic.edu
National NIDCAP Training Center
Boston Children’s Hospital andBrigham and Women’s Hospital
Boston, Massachusetts, USA
Director: Heidelise Als, PhD
Contact: Sandra M. Kosta, BA
email: nidcap@childrens.harvard.edu
NIDCAP Cincinnati
Cincinnati Children’s Hospital Medical Center
Cincinnati, Ohio, USA
Director: Michelle Shinkle, MSN, RN
Contact: Linda Lacina, MSN
email: Linda.Lacina@cchmc.org
South America

ARGENTINA

Centro Latinoamericano NIDCAP & APIB
Fernández Hospital
Fundación Dr. Miguel Margulies andFundación Alumbrar, Buenos Aires, Argentina
Director and Contact: Graciela Basso, MD, PhD
email: basso.grace@gmail.com

34 • 2022 • Developmental Observer

OCEANIA
AUSTRALIA

Australasian NIDCAP Training Centre
The Sydney Children's Hospitals Network Westmead, Australia
Co-Directors: Angela Casey, RN, BN and Kaye Spence, AM, MN
Contact: Nadine Griffiths, NIDCAP trainer
email: SCHN-NIDCAPAustralia@health.nsw.gov.au

EUROPEBELGIUM

The Brussels NIDCAP Training Center
Saint-Pierre University Hospital Free University of Brussels
Brussels, Belgium
Director: Inge Van Herreweghe, MD
Co-Director: Marie Tackoen, MD
Contact: Delphine Druart, RN
email: delphine_druart@stpierre-bru.be
UZ Leuven NIDCAP Training Center
Leuven, Belgium
Director: Anne Debeer, MD, PhD
Co-Director: Chris Vanhole, MD, PhD
Contact: An Carmen
Email: nidcaptrainingcenter@uzleuven.be

DENMARK

Danish NIDCAP Training and Development Center
Aarhus University Hospital, Aarhus N, Denmark
Director: Tine Brink Henriksen Professor, MD, PhD
Co-Director: Majken Grund Nielsen, RN
Contact: Eva Jørgensen, RN
email: auh.nidcaptrainingcenter@rm.dk

FRANCE

French NIDCAP Center, Brest
Medical School, Université de Bretagne Occidentale andUniversity Hospital, Brest, France
Director: Jean-Michel Roué, MD, PhD
Contact: Sylvie Minguy
email: sylvie.bleunven@chu-brest.fr
French NIDCAP Center, Toulouse
Hôpital des Enfant Toulouse, France
Director: Charlotte Casper, MD, PhD
Co-Director and Contact: Sandra Lescure, MD
email: lescure.s@chu-toulouse.fr

GERMANYNIDCAP Germany, Training Center Tübingen
Universitätsklinik für Kinder- und Jugendmedizin
Tübingen, Germany
Director: Christian Poets, MD, PhD
Contact: Natalie Wetzel, RN
email: natalie.wetzel@med.uni-tuebingen.deNIDCAP TRAINING CENTERS

ITALY

Italian Modena NIDCAP Training Center
Modena University Hospital, Modena, Italy
Director: Fabrizio Ferrari, MD
Contact: Natascia Bertoncelli, PT
email: natascia.bertoncelli@gmail.com
Rimini NIDCAP Training Center
AUSL Romagna, Infermi Hospital, Rimini, Italy
Director and Contact: Gina Ancora, MD, PhD
Co-Director: Natascia Simeone, RN
email: gina.ancora@auslromagna.it

THE NETHERLANDS

Sophia NIDCAP and APIB Training Center
Erasmus MC-Sophia Children’s Hospital
Rotterdam, The Netherlands
Director: Nikk Conneman, MD
Co-Director and Contact: Monique Oude Reimer, RN
email: nidcap@erasmusmc.nl

NORWAYNIDCAP Norway, Ålesund Training CenterÅlesund Hospital, Ålesund, Norway
Director: Lutz Nietsch, MD
Contact: Unni Tomren, RN
email: nidcap@helse-mr.no

PORTUGALSão João NIDCAP Training Center
Pediatric Hospital at São João Hospital
Porto, Portugal
Director: Hercília Guimarães, MD, PhD
Co-Director and Contact: Fátima Clemente, MD
email: nidcapportugal@gmail.com

SPAIN

Barcelona NIDCAP Training Center: Vall d’Hebron and
Dr Josep Trueta Hospitals
Hospital Universitari Vall d’Hebron, Barcelona, Spain
Director and Contact: Josep Perapoch, MD, PhD
email: jperapoch.girona.ics@gencat.cat
Hospital Universitario 12 de Octubre NIDCAP
Training Center
Hospital Universitario 12 de Octubre, Madrid, Spain
Director: Carmen Martinez de Pancorbo, MD
Contact: María López Maestro, MD
email: nidcap.hdoc@salud.madrid.org

SWEDEN

Karolinska NIDCAP Training and Research Center
Astrid Lindgren Children’s Hospital at Karolinska University
Hospital Stockholm, Sweden
Director: Stina Klemming, MD
Co-Director: Björn Westrup, MD, PhD
Contact: Ann-Sofie Ingman, RN, BSN
email: nidcap.karolinska@sll.se
Lund-Malmö NIDCAP Training and Research Center
Skane University Hospital
Malmö, Sweden
Director: Elisabeth Olhager, MD
Contact: Stina Klemming, MD
email: nidcap.sus@skane.se

UNITED KINGDOMUK NIDCAP Centre
Department of Neonatology,
University College Hospital, London, UK
Director: Giles Kendall, MBBS, FRCPCH, PhD
Contact: Gillian Kennedy, OBE, MSc
email: gillian.kennedy4@nhs.net

MIDDLE EASTISRAEL

Israel NIDCAP Training Center
Meir Medical Center
Kfar Saba, Israel
Co-Directors: Ita Litmanovitz, MD and
Dalia Silberstein, RN, PhD
Contact: Dalia Silberstein, RN, PhD
email: dalia.silberstein@clalit.org.il

ASIA
JAPAN

Japan National NIDCAP Training Center
Seirei Christopher University, Shizuoka, Japan
Director: Tomohisa Fujimoto, PT
Co-Directors: Kanako Uchiumi, RN, MW, Noriko Moriguchi,
MSN, RN, PHN, IBCLC & Yoko Otake, RN
Contact: Tomohisa Fujimoto, PT
Email: fusan.mail@gmail.com

Sant Joan de Déu Barcelona NIDCAP Trainer Center
Sant Joan de Déu Hospital
Barcelona, Spain
Director and Contact: Ana Riverola, MD
Email: ariverola@hsjdbcn.org

2022 • Developmental Observer • 35

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