Streaming Media

Name of Corresponding Author

Sue Horner

Credentials of Corresponding Author


Name of Faculty Advisor

Dr. Lee Schmidt


Annually nearly one-half million infants are admitted to Neonatal Intensive Care Units (NICU) in the United States. NICU infants are at significant risk for adverse neurodevelopmental outcomes that may persist into adulthood. Toxic stress is severe, repeated or prolonged activation of the stress response system during critical periods of development, in the absence of buffering relationships. NICU infants are exposed to frequent stressors, including separation from parents, during sensitive periods in development. These cumulative stressor exposures contribute to adverse neurodevelopmental outcomes observed in this population. Developmental care (DC) seeks to integrate neuroprotective practices with required NICU care, and an overarching goal of DC is to mitigate infant stress. A growing body of evidence supports DC to improve infant outcomes, but DC is not consistently implemented in NICUs. Implementation of DC may be influenced by evidence supporting use of DC interventions to mitigate NICU infant stress.


The purpose of this review was to synthesize the state of the science regarding the impact of DC interventions on stress in NICU infants.

Search strategy

The literature was searched for clinical trials reporting infant stress-related outcomes associated with the implementation of 11 common DC programs and practices.

Results of literature search

Ninety-nine papers met inclusion criteria and were included in this review. Seventy-five papers reported clinical trials: 66 trials were of fair to good quality.

Synthesis of evidence

Associations between DC interventions and reductions in NICU infant stress were observed in 53 trials. A summary table was used to describe the number of clinical trials reporting positive associations between reduced infant stress and DC interventions according to postmenstrual ages (PMA) of infant subjects. DC interventions with the largest number of studies reporting reductions in NICU infant stress were kangaroo care followed by Newborn Individualized Developmental Care and Assessment Program. Infant stress was most often measured using neurobehavioral examinations.

Implications for practice

Variations in timing and dose of DC interventions, and variety of DC interventions reported, make it difficult to generalize results of DC intervention trials. Recommendations for future research include using biomarkers of stress as outcome measures and use of large, longitudinal studies to examine associations between DC interventions and infant stress-related outcomes in the NICU.



Developmental Care to Mitigate Stress in NICU Infants: State of the Science