Developmental Care: Best Practices for our Babies

When a baby has a complex heart defect, their early experiences are often unusual. Instead of being at home in their neighborhoods, many babies with complex heart defects are in a cardiac intensive care unit (CICU), where they can experience stressors such as:

• bright lights

• beeps and other noises

• many caretakers

• painful and uncomfortable procedures

• separation from a parent 

Developmental Care practices aim to create a more typical experience for a developing child by focusing on the rights and needs of the child and family. When hospitals use Developmental Care, babies are usually healthier and happier.

When a hospital uses Developmental Care, they support the comfort and dignity of each child and family. Parents and clinicians prioritize the developmental needs of each child as they plan and deliver their care.

The practices described below are helpful for many babies and families. As always, adults should look to the babies themselves in planning care. Babies can communicate what they need, what works for them, and what should be avoided. When the whole team is sensitive to babies' cues, they can work together to customize care that is right for each child.

Babies usually do best when caregivers are able to hold them as much as possible. This means:

• Adults pay attention to a baby's cues indicating when, whether, and how they want to be held.

• Hospital staff ask for, listen to, and respect family preferences around holding.

• Parents hold their babies very frequently.

• Parents hold their babies for long periods of time (up to 24 hours).

• Parents hold their babies skin-to-skin.

• All hospital staff encourage and support parents in holding their babies.

• Parents have a comfortable environment for holding, including recliners, food and drink, relative privacy, and relative stillness/quiet.

• Staff support parents in doing a "hand hold" when babies must remain in a bed, by cupping the baby with one hand on their head, and the other on their swaddled bottom.

Choices in bedding and clothing can significantly affect the experience of a hospitalized baby and their family. When bedding and clothing are selected based on individual needs and preferences, children and their families often feel more comfortable and relaxed. This may mean:

• Bedding and clothing are creatively selected according to each child's needs and preferences.

• Babies may be offered sleeping options such as a bunting or hammock.

• Babies have the option of a variety of pacifiers, including ones that give them something to grip.

• Canopies, visors, and tents are available to shield light and block visual stimulation.

• Babies have soft, appropriately-shaped, well-sized diapers.

• Baby clothing is soft and well-fitting.

• Babies are safely covered with soft blankets.

• Parents are supported if they want to live in with their baby, and to hold their baby as much as possible.

Developmental Care practices can help babies to regulate their state, emotions, and behavior. When hospitals use Developmental Care, parents work with staff to promote each baby's emerging self-regulation. Depending on an individual child, self-regulation strategies can include:

• A parent holds the baby frequently and for a long time.

• A parent holds the baby skin-to-skin.

• A parent caresses the baby.

• A parent cups their hand around a baby lying on a bed.

• Caregivers swaddle the baby in soft cloth.

• The baby has a pacifier, nipple, or clean finger to suck on.

• The baby holds a parent's hand or finger.

• The baby is contained by bedding and supports.

Well-planned positioning and movement can keep babies calm and regulated, and can help their bodies to develop as well as possible. For many babies, developmentally- appropriate positioning and movement can mean:

• The baby's arms and legs are bent (flexed) most of the time.

• Most of the time the baby's knees, feet, and nipples all point the same direction.

• The baby's hands are often near their mouth.

• Caregivers regularly change the baby's position while following their cues. Most young babies can spend time on their back, side, tummy, and upright with support. Older babies may also be able to sit or stand.

• The baby is often swaddled, cupped, or otherwise supported and contained.

• When it is safe to do so, the baby can actively move and explore with their body.

• When it is safe, a baby does passive range of motion (PROM) exercises, with an adult gently moving their body.

• Caregivers regularly watch the baby, and look for signs in the baby's posture, movement, and tone that the baby is regulated. For example, a well-regulated baby usually makes smooth organized movements, has flexed limbs with relaxed fingers, is able to bring their hands to their mouth, and has a relaxed back.

• Staff work together with families to position the baby's body throughout the day and night to promote regulation, developmental progress, and healthy growth.

Feeding practices are central to babies' development and well-being, and are embedded within the culture of each family and community. Developmental Care practices support the individual feeding needs of each child and family. This usually means:

• Parents are recognized as the child's most important source of nurturing and nutrition, and are central in guiding and providing feeding.

• Parents and staff consistently watch the baby for signs that the child is alert, hungry, and ready to eat.

• Parents or staff feed the baby when the baby shows that they are hungry and ready to eat.

• The baby's communication determines the pace and length of feeding.

• Rooms are calm, warm, and lit with indirect light.

• During feedings, parents or other caregivers support babies and hold them close.

• During feedings, parents and staff help babies to grasp a finger, pacifier, or other object.

• The baby can take rests during their feeding according to their needs and preferences.

• The baby can nuzzle and lick their mother's breast, even if they are not currently breastfeeding.

• When parents want to breastfeed, staff members encourage, support, and facilitate them.

• Caregivers physically and emotionally support the baby after eating, and gently transition them back to sleep or to a state of quiet alertness.

• The parent uses slow and gentle repetitive movements such as rubbing, patting, walking, or bouncing.

• Parents and staff follow a child's cues at all times, continually focusing on the goal of helping the child to relax.

• The care team looks to the parents as the child's primary source of nurturing and care.

Diaper changes and skin care routines are necessary, but they can make babies become agitated or distressed. Parents and staff can consider these Developmental Care practices in designing a care routine for each baby:

• Responding to a baby's cues, parents and staff adjust lighting, sound, temperature, and other features of the environment to keep the baby as calm as possible before, during, and after a care routine.

• Caregivers place the baby in a comfortable, contained, and well-supported position.

• Caregivers gently help the baby flex their ams and legs, and bring their hands to their mouth.

• During the diaper change or skin care, parents pay attention to the baby, respond to their cues, and provide reassurance and support.

• Whenever possible, the team waits until the baby is well-regulated before beginning diaper changes or skin care.

• Diapers and skin care products are soft, gentle, appropriately-sized, and a comfortable temperature.

• Parents take the lead in performing a child's physical care, with assistance as needed.

Bathing can sometimes disrupt babies' fragile self-regulation. These Developmental Care practices can support many babies before, during, and after their bath:

• The timing, frequency, and duration of baths are adjusted based on each child's needs and preferences.

• Caregivers bathe babies when they are calm and alert.

• The room is quiet, warm, dimly lit, and relaxed.

• Throughout the bath, parents and other caregivers pay attention to the baby and respond to their communication with comfort and support.

• Throughout the bath, adults support and contain the baby's body. In many cases, babies may stay calmest when a parent cups them with their hands

• Caretakers swaddle the baby in blankets before lowering them into the bath.

• Caregivers gently help the baby to bend their arms and legs, and to bring their hands to their mouth.

• The baby has a pacifier or something else to suck on.

• Caregivers consistently move calmly, slowly, and gently.

• The baby is immersed in deep, warm water.

• When safe, parents are encouraged to bathe together privately with their baby.

• After a bath, parents and staff contain and support the baby, and gently transition them to drying and dressing.

• Parents take the lead in bathing their own baby, with assistance as needed.

When care practices serve each unique child, they must be timed around that child's schedule, needs, and preferences. Careful timing of care can help children stay well-regulated, which in turn can help them to rest, heal, grow, and learn.

Mindful timing can mean:

• The care team carefully considers the child's sleep/wake cycle, feeding routines, and developmental goals when planning care, treatments, and services.

• The baby's schedule is planned to maximize age-appropriate periods of uninterrupted sleep.

• The baby's schedule is planned to provide opportunities for learning and connecting during age-appropriate times of prolonged calm alertness.

• The timing and duration of activities are based as much as possible on an individual child's self-regulation needs.

• Whenever possible, care routines, therapies, and treatments move at a pace that is comfortable for the child, based on the child's cues.

• Caregivers plan the order of activities based as much as possible on an individual child's needs and preferences.

• The baby's parents take a leadership role in timing care and in helping their child to regulate.

When using Developmental Care, parents and clinicians plan services and supports based on each child's preferences and developmental needs. This can mean:

• Caregivers support the child's self-regulation before, during, and after each activity.

• Parents and staff look for opportunities to reduce stress and improve regulation throughout the baby's day

• Parents and staff use strategies to reduce stress proactively, and try to prevent the need for more invasive procedures.

• Parents and clinicians consistently monitor the baby's state, and respond to the baby's cues by modifying their care.

• Parents take the lead in planning their child's care to optimize their development.

Any transition can be stressful to a fragile baby who is trying to self-regulate. As part of Developmental Care, well-planned transitions can help babies to stay relaxed and organized. These strategies can help many babies to stay well-regulated during transitions:

• Any time the baby is transitioning between spaces, states, positions, caregivers, or activities, the care team plans how to support the baby before, during, and after the transition.

• Whenever possible, a transition starts after the baby shows that they are calm.

• Rooms are consistently warm, dim, quiet, and relaxed.

• During a transition, people in the room remain quiet, and move slowly and calmly.

• Caregivers gently and comfortably contain a baby throughout each transition, often with the baby's arms and legs flexed, and with their hands near their mouth.

• The baby has something to suck on and something to grab.

• During the transition, caregivers modify any optional parts of the activity in response to the child's cues.

• If the baby becomes agitated, the care team pauses and calms the baby before continuing the transition.

• If a baby remains agitated, caretakers stop and postpone the activity if possible. They change their plans for future activities based on what they learned about the baby's needs and preferences.

• Parents take the lead in planning their baby's transitions, and in supporting their baby surrounding transitions.

Babies need time and support to develop a sleep/wake cycle, and to adapt their level of alertness to the environment. Parents and hospital staff can help babies to become increasingly successful and independent in regulating their state of arousal. This can means:

• Caregivers consistently monitor a baby's state, and they plan and adjust their caretaking based on the baby's state.

• When a baby is asleep, caretakers make the baby contained and comfortable. They dim the lights, reduce noise, and avoid disturbing the baby as much as possible.

• Parents and staff soothe and support babies as they are changing state: when babies are waking up, getting tired, falling asleep, getting interested, becoming upset, or calming down.

• When a baby is awake and alert during the day, parents and staff interact with them, show them things, and play with them.

• When babies show they they are ready for a break or a rest, parents and staff help them to calm down and go to sleep.

• From day to day, parents and staff plan activities to move babies closer to a more mature sleep-wake cycle.

• Parents guide the team in regulating a baby's state and schedule.

Developmental Care is based on a simple principle: children are still children, even if they are sick. They have the same needs, rights, and desires as any other child, and their care should be centered within their family, culture, and community. When caretakers keep this principle in mind, they are much more successful at building spaces and providing care that promotes the well-being of the whole child.

Developmental care is best when it is local. Families local to Boston can receive care from the Cardiac Neurodevelopmental Program (CNP). Families from other regions can use the link below to find their local care team.