Table of Contents

Family Voices ............................................. 1

Message from the NFI President ........... 3

NIDCAP Training Centers from Around  
 the World ................................................ 7

The Neuroscience of Skin-to-Skin  
 Contact .................................................... 8

NIDCAP Reflections................................ 10

NIDCAP Profile ........................................ 12

Supporting Families ................................ 13

Current Developmental Research ........ 14

Developmental Resources .................... 15

Letters to the Editors .............................. 17

Donnisha McCadden has had three pregnancies. The first two led to the birth of 
three extremely early born infants, who were too young to survive. Then one year 
after the second pregnancy, Donnisha and her partner, Gary Boyd, were expect-
ing another set of twins. Their story was gathered from telephone interviews.

The Pregnancy and the Birth
DONNISHA: I found out I was pregnant very early on. I was maybe around four to 
six weeks pregnant. I got the cervical circlage around three months. My doctor took me 
out of work. As the babies started to gain weight, lying around all day became strenu-
ous. However, I did it. 

GARY: Donnisha was pregnant with twins and we had a test in the hospital where they 
stuck a needle down in her belly and took some amniotic fluid. Gabby was supposed to 
be the one that had the worst possibility of making it. They were talking about a whole 
host of things that could have been wrong with her. The baby that was positioned 
lower in the uterus, her brother Gavin, was fine. No issues whatsoever. So we were 
most concerned about Gabby. Tenfold.

DONNISHA: When the babies actually started to get heavy is when the premature 
labor started for me. I went into labor on December 27th, two days after Christmas 
and the doctors and nurses 
did everything they could 
to stop it and it actually 
stopped. Maybe a day or 
two later, I got transferred 
to Cooper University 
Hospital (in Camden, New 
Jersey) and the doctors gave 
me magnesium (sulfate) to 
stop my labor and it finally 
worked. So I stayed in the 
hospital actually for a week 
and that was a good thing. 
I think that, that week, I 
was happy because I was 
like okay “I can do this, I 
can do this, I can do this.” 
Then the circlage started to 

2008 Vol. 2   No. 2 

NIDCAP Federation  
International (NFI)

Founded in 2001, the NFI is an  
international, non-profit membership 
organization. The NFI encourages the 
implementation of developmental care 
and assures the quality of the Newborn 
Individualized Developmental Care  
and Assessment Program (NIDCAP)  
approach in all intensive and special  
care nurseries around the world.  
The NFI serves as the authoritative 
leader for research, development,  
and dissemination of NIDCAP, and 
for the certification of trainers, health 
care professionals, and nurseries in the 
NIDCAP approach.

Developmental 
  Observer
The Official Newsletter of the NIDCAP® Federation International

Family Voices
Donnisha McCadden & Gary Boyd 

“Courage is what it takes to stand up 
and speak; courage is also what it 
takes to sit down and listen.”

Winston Churchill

Continued on page 2

Developmental Care in the Moment

photograph by Karin Schrage-Hoon

Comforted.



�  •  �008  •  Developmental Observer

break and open and they needed to take it out. When they did 
take it out my water broke, however, I still didn’t go into labor. 
They thought that Gavin was going to come out but he didn’t, 
they both stayed in. And I was happy about that. Very happy. 
Then an infection set in, and that caused me to go into labor. 
However, it was a week later, thank God. 

The birth for Gabby and Gavin was very stressful because 
of how intense my labor was and how fast it progressed. I started 
labor in the wee hours of the morning, maybe three o’clock. How-
ever, the nurses were checking on me because they realized I had a 
fever that kept going up. I wasn’t telling them that I was in labor, I 
just kept moaning because I was trying to hold them in as long as 
I could. Gavin was born at ten something and Gabby was born 
an hour later. 

GARY: When Donnisha was in the hospital she caught an infec-
tion and it infected my son. He didn’t make it.

DONNISHA: Gabby was one pound six ounces and she was 
born at 24 weeks. She had just turned six months to the day 
when I had her and Gavin. It was very stressful. She was actu-
ally coming out in her water sack. I remember, that her dad 
said when we got to the end, she tried to open her eyes but she 
couldn’t she was too premature but she did try… My birthing 
experience was not a pleasant one, not for me.

The Newborn Intensive Care Unit
DONNISHA: Well… the ever-going roller coaster that they say 
happens, it definitely happened. First week, first three to four 
days, Gabby seemed fine, no problems, she needed a little bit of 
oxygen, then we went down the roller coaster with her catch-
ing an infection. They were trying to feed her, and then she had 
green (stools) so they gave her antibiotics. Then Gabby starts to 
progress with her eating, then we go back down with her eating 
through the tube. And then we go back up another roller coaster 
and then we go down with an infection, her blood culture is not 

coming back correctly. It was a trying time. Then Gabby had 
jaundice. It was just a lot. It was just a lot to see how small she 
was when she was born that young. She was very, very tiny. Her 
skin was transparent. Honestly, looking at her now and then, it’s 
been remarkable. It’s a remarkable change. She is totally Gabrielle. 
Totally her own person now. A totally different person now.

Not only was her medical course a roller coaster, but it was 
also a very emotional roller coaster. Your emotions are high 
and then they are low, then they are high and then they are low 
again. It’s a very stressful situation to be in. However, you have to 
do what you have to do. You can’t just look at their little bodies 
and say “oh well,” and then you don’t come, you don’t visit them, 
you don’t sit with them, you don’t talk to them, you don’t hold 
their little hands, you don’t participate in the day to day care. I 
feel that would make them decline as far as their health and their 
getting bigger and growing stronger. That’s my opinion. 

I was there as long as I could be there. In the beginning, 
I would go and stay there all day, until eight or nine o’clock at 
night. If the doctors were coming and doing rounds or a change 
in shift, I could basically tell them what happened. That’s how 
much I was there. Gabby had this, this, this, that and the other; 
this is up, this is down. I could do that. Gabby needed me. Be-
cause of her prematurity, she still needed the warmth from me. 
And honestly, I kangarooed as much as I could. I was a nervous 
wreck in the beginning because she was so small. Her dad kanga-
rooed when she was almost two pounds. I was so nervous about 
doing that because, I just felt like she was so tiny. I couldn’t do it, 
but her dad did it. And afterwards, I got used to it. 

I felt like the doctors and nurses were my family. You cried, 
they cried. It was like one big family all the way down to the re-
ceptionist. It was nice. The head doctor, Dr. Stahl, was wonder-
ful. In my eyes it is amazing to me, because so much individual 
attention normally doesn’t happen. If I was just going to the hos-
pital on a regular visit, I’m not going to get to see the head doc-
tor. That was very supportive in my opinion. The doctors and 

A semi-annual publication of the NIDCAP Federation International  
© 2008. Articles from Developmental Observer, duly acknowledged, 
may be reprinted with permission. Please contact us at:  
developmentalobserver@nidcap.org.

Senior Editor Rodd Hedlund, MEd

Associate Editors Deborah Buehler, PhD
    gretchen Lawhon, RN, PhD

Text Editor  Sandra Kosta, BA

Printed on recycled paper

NIDCAP Federation 
International (NFI)

Contributions
We would like to thank all of our individual donors and the following foun-
dations for their generous support of the NFI and its continuing work:

 A.L. Mailman Family Foundation
 Bella Vista Foundation 
 Pritzker Early Childhood Foundation

Developmental 
  Observer

Continued on page 5

Family Voices Continued from page 1



Developmental Observer  •  �008  •  �  

When recently 
visiting a rela-

tively wealthy North 
African country, I had 
the opportunity to 
visit the capital city’s 
University Children’s 
Hospital NICU. I 
stepped into a barren, 
grey, factory-like open 
hall with cold fluores-
cent ceiling lights over 
metal cots and large, 
bulky milky-plastic in-
cubators lined up along 

a seemingly endless long wall. Shrill alarm, pager and telephone 
sounds incessantly pierced the air. I had come with high expecta-
tions. Suddenly I felt transported back to the NICU-world of 
the 70’s in the United States. Despite the Internet and on-line 
worldwide access to many professional publications, and numer-
ous international medical congresses, thousands of emaciated 
and limp infants, clad only in huge plastic diapers, still lie on 
their backs, depressed and alone in many countries and cities all 
over the world. Newly admitted infants, arching and protesting 
their treatments and abandonment quickly become subdued by 
relentless routine intensive care that emphasizes equipment and 
antiseptic procedures above all else. 

It is difficult and painful to remember that just 30 years ago 
most NICU care was like that. Only professionals were admit-
ted to the Unit. Loudspeakers overhead incessantly announced 
lectures and doctors’ pages from anywhere in the entire hospital. 
Cleaning buckets and buffing machines, and those who operated 
them, merrily entered the NICU at any time. Staff members, 
well intentioned, called to one another from the entrance door to 
the farthest incubator’s nurse and doctor. 

The understanding we have gained over the past three 
decades in reading the infant’s language has made it increasingly 
clear that the parents are quintessential and critically important 
to ease the infant’s often abrupt and unexpected transition from 
the womb to the NICU. We have learned that parents are the 
best medium for healing and development. Gradually parents’ 
presence has become increasingly familiar to the technically 
trained NICU staff. Early on, parents were often relegated to 
standing at the incubator for short periods of time, as they 
gradually gained the trust of the staff that indeed they know 
and care deeply about their infant. Yet they also dutifully leave 

when the messages (whether spoken, in gesture, explicit in the 
emotional ambience, or the physical environment) tell them that 
they have outstayed their welcome. Often the parent booklet 
they receive states explicitly that they are invited to come at any 
time, 24 hours around the clock. Yet, still today in too many 
NICUs, even in those with individual family rooms for each 
infant and family, it’s still a struggle for staff to live up to their 
own best proclamations. The mother or father who comes to be 
with their infant at seven o’clock in the morning and reluctantly 
leaves at eleven o’clock at night, may still today, in a modern 
NICU, be described as “controlling” and mistrustful of the staff ’s 
skill and caring. Much staff education, emotional support and 
guidance is still required to effectively enhance staff confidence 
and trust to truly value the parents as collaborators and their 
infants’ foremost caregivers, nurturers, and life-long safe havens. 
Less psychologically demanding innovations over the last 30 
years have become standard care by now in many US and Euro-
pean NICUs  (e.g. all infants have nests and many incubators are 
covered; everyone appears to know about the importance of non-
nutritive sucking, of support to midline positions, and of the 
values of skin-to-skin holding or kangaroo care). The bigger step 
is the astute appreciation of each infant’s thresholds to stress and 
the conclusions to draw from this recognition for the individu-
alization of care and experience for infant and family, including: 
the slow pacing of care; feeding only while holding the infant; 
support to falling and staying asleep while held for prolonged pe-
riods; and the many subtle aspects that truly enhance an infant’s 
competence and reduce stress. While everyone is concerned 
about brain growth and nutrition, the way the nutrition is deliv-
ered and received by infants still poses a challenge. The infant’s 
active partnership in all care collaboration, the only way that care 
may become effective as intended, is a continued and active topic 
for staff education.

The situation becomes startling when all of the consider-
ations are still below the threshold of conscious staff awareness: 
a NICU where mothers come reliably every morning to bring 
the milk that they have pumped at home for their infants and 
pass it through a small window to an anonymous hand on the 
other side; where parents come every day at a fixed hour in the 
afternoon for 10 minutes to stand in a dilapidated corridor 
and look into the NICU through a dirty, milky, scratched glass 
window, to see only the incubators and perhaps catch a glimpse 
of their infant’s feet as they extend toward the foot end of the 
incubator; or hear an infant, maybe their own infant, cry with 
no one to attend to and comfort the upset child; where nurses 
with sad, yearning eyes wistfully care for their forlorn charges 

Message from the NFI President

The Courage to Trust 



�  •  �008  •  Developmental Observer

with little hope to find understanding from their leadership; and 
where money is spent on technical innovations yet is not avail-
able for pacifiers, blankets, chairs, and support and education to 
nurses and young doctors, who are still hopeful and seek to make 
a difference. Every day the staff cares for the smallest and sickest 
infants, every day they sustain the pain of their forlorn charges, 
their emotions and creativity held down, restricted and bent 
to the rules that govern the system from the top. When death 
is almost hoped for and is the likely future of a preterm infant; 
when families are left to their own devices for rehabilitation and 
care should their infant survive the NICU; when even those with 
minor disabilities can expect a future fraught with difficulties; 
then NIDCAP and the NIDCAP stance and spirit are very much 
warranted as critical care components within the hospital system.

NIDCAP, a systems approach, helps bring about systemic 
change, not only NICU and hospital system change, but also 
societal and political system change. Each infant and each family 
count. Each infant and each family are valuable. But where to 
begin? Anywhere is better than not at all: one infant and one 
family at a time; one nurse and one doctor at a time; one NICU 
and one hospital at a time; one city and one country at a time.   
This is the only way to create the necessary change.

 The medical visitors to this NICU were taken “on tour by 
the medical director,” while the nurses stepped out of the way. As 
there were no explicit rules for psychologists, I took the liberty 
to look and smile at the nurses. They gathered quickly around 
me, and despite our language barrier, they clearly were eager to 
learn why I was there. In just a few minutes we stood together 
at a bedside and watched a little boy, who was severely growth 
restricted, lay flat on his back, flailing his arms, his shoulders 
retracted and pulled high up to his ears. He arched and screamed 
in utter despair with his mouth wide-open, ashen grey despite his 
arousal. I gestured that he might enjoy being tucked in and have 
something to suck on. The nurses shook their heads in sadness. 
He was not allowed to eat now. I tried to convey that sucking 
might help even without food. They looked at me, incredulous. 
They had never heard of pacifiers and the hospital had none.  
With gestures and mime, one nurse understood the concept and 
went to fetch a nursing bottle. We fashioned a pacifier out of the 
nipple and stuffed it with a piece of cotton cloth. “Now what?” 
they seemed to ask. When I then supported and guided one of 
the nurses to open the incubator and gradually place her hands 
around the infant’s feet and legs and speak to him softly, then 
gather his hands in her hands, this helped his shoulders to relax, 
and he gradually looked at the nurse and calmed somewhat.  
When I now guided her to help him onto his side and to cradle 
him with her right arm, she spontaneously, with her left hand, 
supported his grasp, and all the while she spoke very softly to 
him, her eyes became shiny, her face soft and caring. The other 

nurses stood and watched, astounded and taken by the little 
boy’s visible transformation in interaction. One nurse went to 
get some more of the cotton cloth and we made a soft cradle roll 
to support the little boy along his back. The nurse engaged with 
him, gently took the makeshift “pacifier” we had made, and held 
it close to the infant’s lips. While still crying softly, he grasped 
the pacifier with both hands and pushed it into his mouth, 
sucked like fury, and looked with wide eyes directly at his nurse. 
She in turn was glued to him and kept her eyes on him. Her 
hand cradled his body and she slowly covered him gently with 
another cloth that her colleague miraculously produced. The 
little boy gradually calmed and drowsed off to sleep, as the paci-
fier dropped out of his slightly parted, relaxed lips.  Very gently 
the caregiving nurse pulled her hands one by one out of the in-
cubator and softly closed its doors. Her face, her posture and her 
whole being had changed, becoming soft, fluid, and caring. The 
nurses crowded in on me. How can they learn more? How will 
they convince the doctors to help them learn more? How will 
they bring in the mothers and fathers? The bravest of the nurses, 
who had just helped the little boy, confided with tears in her eyes 
that she had smuggled the father of one of the infant’s into the 
NICU several times in the evening, when she felt it was safe. She 
had observed what it meant to the infant to have his father talk 
to him and even briefly hold him. No wonder she was so open to 
try the next step under the guise of my visit. 

This is but a tiny yet important seed in the beginning of a 
garden. I am convinced that with the courage to trust in our-
selves, in the infants, in the parents and the staff of nurseries 
everywhere, we will multiply trust, courage, creativity, and gen-
erosity and the effectiveness to bring about change on behalf of 
infants, families and professionals in intensive care everywhere. 
Political agendas are made and carried by people. People all 
share in the same basic human heritage of empathy, caring, and 
responsibility for one another. NIDCAP must be a spark and an 
initiative that helps make the thousands of seeds of opportuni-
ties, to swell, sprout, and grow, even when seemingly buried deep 
in arid soils. Together we are strong and will continue to forge an 
agenda of national and international change and growth. 

        —Heidelise Als, PhD



Developmental Observer  •  �008  •  �  

nurses acted in my place for me when I couldn’t be there. Her 
primary nurse, Pat, was excellent. All the nurses knew Gabby.  
All the nurses knew me. I just will never forget these people. 
They made such an impression on my family and me. The hon-
esty that they provided was especially helpful. Say for instance, 
Gabby was not having a good day. They would tell you that 
“This is not a good day for Gabby. Her cultures came back with 
an elevated white blood cell count. She hasn’t been breathing on 
her own. Her oxygen level had been turned all the way up. She 
has only been breathing at 85%.” Some nurses would just lay it 
down for you straight. However, during those times her nurse 
would stay there and would not leave until she felt comfortable 
enough to leave Gabby with another nurse to take over. So like  
I said they went through it with you. Everyone worked together.

Unfortunately she still wasn’t able to breath on her own  
for a long time. Being on the oscillator is a scary thing. Gabby 
progressed backwards. As she got bigger then she needed  
more oxygen, more for her lungs to open up. That was a scary 
experience. You would come in, the baby vibrating, the machine 
vibrating. One day it’s turned up, the next day it’s turned down. 
Very scary. Then also, because they’re so tiny, they’re not able to 
find veins as quickly as they can on a bigger baby. There were 
days when I would come in and Gabby would have a needle in 
her arm, but that vein would soon collapse and the nurse would 
have to find a vein in her other arm. It was like: “Oh man, you 
just keep sticking my poor baby.” 

My experience at the Ronald McDonald House was also 
wonderful. There was another parent, whose daughter was born 
two days from Gabby. We went through this whole ordeal togeth-
er. We would call each other. “Hey, are you going to the Ronald 
McDonald House this weekend? “Yes.” We would connect there. 
We would go sit with the girls. Hold the girls. Do whatever we 
needed to---Kangaroo. My experience was just so wonderful. I 
don’t know how else to describe it. It was just beautiful.

After awhile, it got to the point where I was sort of like the 
lead parent for the new parents in the nursery. I would tell them: 
“You know you are going to go through a roller coaster and 
trust me you are going to have your ups and downs. Don’t pay 
attention to the oxygen monitors because sometimes if your baby 
makes a sudden movement it may kick the lead off.  When that 
happens the monitor will go beep, beep, beep. If you go through 
that, and if you are by yourself, and your family is not there to 
support you…..you need someone to talk to….. a shoulder to 
lean on….. a shoulder to cry on. I tried to be there for par-
ents. I guess that’s my nature. I always kept other people in my 
thoughts, and their families in my thoughts, and their child in 
my thoughts. As I prayed for Gabby, I prayed for others too.”

Life at Home
GARY: When Gabby first came home it was very interesting 
because she came home with a monitor. So it’s one thing to be 
in the hospital and be there with a monitor because you sort of 
become numb to all of the bells and whistles. When you’re at 
home with a monitor that’s a different experience. It would go 
off sometimes for basically no reason at all. We hated it. Luck-
ily she wasn’t on it long, but it was an adjustment. To be hon-
est with you, Gabby isn’t like a lot of others because she slept 
through most of the night.  Maybe once or twice we woke up at 
two or three in the morning to feed her, but for the most part, 
she slept through the whole night. It was a blessing. When she 
slept through the night then we could sleep at night, and then 
during the day, we took turns caring for her.

Gabby can be a handful. When you are alone with her, you 
have to keep up with her, because she’ll be into a whole host of 
stuff. The hardest part right now is catching up with her!  She’s 
all over the place. She really is into everything, but it’s great. The 
most rewarding part is knowing where she came from and how 
hard it was for her and how much she had to fight and where’s 
she’s at now. 

DONNISHA: Gabby is such a daredevil. Everyone at Cooper 
basically said that she was going to have a feisty personality. Even  
as a baby, even when she was that small the staff would say: 
“Oh Gabby is going to be something.” And Gabby is something. 
Now, Gabby will jump off the couch and bed. Gabby has lots of 
personality. And they said that at Cooper. In the beginning, all 
she could do was grunt. Premature babies grunt a lot. Even with 
all the grunting she did her personality shined through. And it 
kicks out definitely now, because she is talking.  

 It really was a joy to watch the things that she did. And 
watch her develop and watch her get bigger. We were blessed to 
have Gabby, as sparkling as she is… and with as much personal-
ity as she has.

GARY: Right now it’s been difficult to get her to learn potty 
training. It may take some time. But really that’s not even a 
complaint, its just part of the process. I only went to work for 
part of the day when she was younger. Then as she got older we 
started sending her to a daycare school with the other kids. There 
she advanced even more, she picked up so much from them. 
When they say children’s learning is like a sponge, Gabby is like 
a sponge. She repeats everything you say and mimics you and she 
learns. She learns very fast. 

I have a son who is fourteen and a daughter who is eleven. 
Gabby sees them all the time. They love her and she loves them 
even though she has started to drive them crazy. That’s her job.

Family Voices Continued from page 2



�  •  �008  •  Developmental Observer

What We Learned
GARY: Learn as much as you can so you can make informed 
decisions about your child’s care. I think that’s very important 
because sometimes we had to make decisions about whether we 
wanted this or that. There was a point around eleven days where 
Gabby didn’t eat, the doctors and nurses were trying to figure out 
certain things about her care, and they were giving her all of her 
nutrients she needed but she wasn’t eating. After a while, I said, 
“wait a minute she’s not eating and I have a problem with that.” 
If you have a question, ask the doctors and nurses. Get to know 
your nurses because the nurses are extremely important. The 
doctors come around, they make their rounds, they make their 
medical diagnoses and then they’re off to the next thing. The 
nurses are there providing that intimate care, that intimate bond 
all the time. So you get to know the nurses because they will 
share with you how your child’s doing on an every day level. The 
nurses tell you the baby responds this way when you get close or 
hold her. The baby likes this or the baby likes that or she was up 
all night. A nurse will tell you when people were coming in or 
out of the room, or whether Gabby perked up or she looked up, 
or she let us know that she knows that she hears us, or whatever 
the case may be. So these are things that are important because 
you need that reinforcement when you go to be with your baby 
and go to hold her. You want to make sure that you establish that 
bond yourself. So learn as much as you can. 

 The best thing to do is to have as much information as 
possible. Gabby got to the point where I told Donnisha one day 
when we came home “when Gabby gets better you’ll know be-
cause she’ll pull that respirator out of her mouth.” The next day, 
she did pull that respirator out of her mouth. She did it twice 
and Gabby got better. 

DONNISHA: Listening to the doctor and participating  
with your child’s care is important. The more connection you 
have with your child, the stronger he or she will become. The  
more time you spend with your baby, the more you do your 
kangarooing, the more you participate with their care….this  
will help a lot.  

Make sure that you do provide the baby with breastmilk, 
because that’s the best milk that you can provide for them at that 
time. Eventually Gabby latched on and it was the most wonder-
ful experience. It was soooo beautiful. Sooo wonderful. It really 
was. Even her dad would say: “You’ve got to go pump for Gabby, 
you’ve got to go pump, you’ve got to go pump.”  Towards the 
end it became difficult because she wasn’t there to make the milk 
come strong. So although I was pumping, it still wasn’t the same 
as her suckling and pulling it out. I went back to work in the 
process and it became difficult.    

Also, you have to have family; you have to have that support 
system. If you don’t have family to help, seek support by net-
working with other parent groups. There are various groups and 
organizations that can help assist you in your time of need. Es-
pecially at Cooper, the nurses make the experience in the nursery 
more like a family than anything else.

Wishes for Our Daughter’s Future
GARY: Everything in the world. Everything! It’s kind of dif-
ficult…..knowing where she came from and seeing her in that 
itty-bitty bed with red skin. She’s chocolate brown now but her 
skin was bright red then because her skin color didn’t come in 
yet. Just remembering that…. I wish the world for her. I wish 
the world for her. Any and everything she wants to do.

DONNISHA: To have a prosperous life. I wish for Gabby 
to strive for anything and everything that makes her happy. 
Whatever goals she wants to attain, I will be there to help her. I 
will help her attain her goals because Gabrielle is still a fighter. 
It’s surprising to me that the nurse at Cooper said: “This one’s 
feisty.” Gabby’s still the same way. She’s five times more feisty be-
cause she’s growing and is bigger now. I wish for Gabby to attain 
any goal that she wishes to and mommy will be there to assist 
her and daddy will be too. 

—Interview by Deborah Buehler, PhD

Holding on to one another.

Developmental Care in the Moment



Developmental Observer  •  �008  •  �  

N I D C A P  T r A I N I N G  C e N T e r s  F r O M  A r O u N D  T h e  w O r l D

In May 1998, a small group of NICU staff (Catherine Mam-
brini, head nurse, Nathalie Ratynski MD and Jacques Sizun 

MD) flew from France to Denver, Colorado to begin NIDCAP 
training. The training and extended discussion with Joy Browne 
were so positive that this core group decided to go on with 
NIDCAP implementation in Brest. This trip was also an op-
portunity to meet the Brussels team from St. Pierre Hospital and 
reflect on the best implementation strategies for Europe. 

In November 1999, Nathalie and Jacques attended their 
first NIDCAP trainers’ meeting in Vermont-- a cultural shock! 
Moving from the medical to the developmental perspective 
entailed a continuous reflective process as individuals and as a 
group. The American welcome was unforgettable and meeting 
the Swedish team was a great support. 

Nathalie Ratynski completed APIB certification in 2003 
with Deborah Buehler, as her APIB trainer, and became a 
NIDCAP trainer in 2004 with Joy Browne as her master trainer. 
The French NIDCAP Center in Brest opened in July 2004. It 
was the second such center in Europe and at that time the first 
French-speaking center. Training began first in the NICUs of 
Valenciennes, France, and then in the university hospital NICUs 
in Toulouse, France and Tivoli, Belgium. Training then contin-
ued on to university hospital NICUs in Montpellier, France, with 
ever growing numbers of hospitals requesting future training. 

Since the beginning of our NIDCAP work, the creation and 
development of the French NIDCAP Center was supported by 
the Dean of the Medical School and the Director of the Hospi-
tal. In order to integrate the NIDCAP training with an academic 
perspective, the French NIDCAP Center was created within the 
University Department for Continuous Education and Training. 
This department is in charge of the administrative components 
of NIDCAP training (contracts with hospitals, invoices, etc.). 

The French NIDCAP Center is affiliated with the Univer-
sity Hospital and the Université de Bretagne Occidentale. The 
Woman, Mother and Child Department, directed by Professor 
Jacques Sizun, has a referral perinatal center with 2500 deliver-
ies per year and a Pediatric and Neonatal Intensive Care Unit 
(PNICU) directed by Dr. Murielle Dobrzynski (medical direc-
tor) and Marie-Christine Nagahapitiyé (head nurse). The unit is 
working very closely with this training center. Its role is not only 
to provide the best care to preterm newborns, but also to be the 
vitrine or “showcase” of NIDCAP philosophy and practices in 
France. In order to coordinate and implement this developmen-
tal approach, a developmental nurse position has been created. 
Sylvie Bleunven-Minguy, the first French NIDCAP-certified 
nurse, has been pleased to accept this role. Each year the unit 
welcomes many delegates from France and abroad. 

One goal of the French NIDCAP Center was to work on 
“changing the system,” at a regional and national level. The 
strategy was to contact and collaborate with national health 
agencies in order to share our experiences and to suggest  
NIDCAP as the best approach in caring for preterm newborns. 
Contacts have been very positive during these past ten years. 
The Haute Autorité de Santé (French National Authority for 
Health), whose mission is to improve quality of care in health 
care organizations, delivered the highest level of certification to 
the Brest University hospital in 2006, with a special note on  
NIDCAP stating that it is “a successful and permanent action likely 
to cause the implementation of similar approaches in other hospi-
tals.” In 2006, the Agence Régionale d’Hospitalisation (Regional 
Hospital Agency, affiliated with the Ministry of Health) included 
NIDCAP implementation into the 2007-2012 regional plan. In 
May 2008, the French NIDCAP Center received the Association 
Nationale pour la Formation Permanente du Personnel Hospitalier 
(National Agency for Hospital Continuous Education) Award.

As the NIDCAP approach was perceived in the 1990’s by 
French professionals as “too American,” efforts were made to 
build a European network to facilitate contact between groups, 
to organize meetings and workshops, and to prepare multi-site 
trials. A grant from the European Science Foundation helped 
to create this network that consisted of the London, Brussels, 
Scandinavian, and Netherlands NIDCAP Centers. In December 
2008, the third Infant Development in Newborn Intensive Care 
Meeting (IDNIC) will be conducted in Paris and organized as a 
joint meeting with the French Neonatal Research Group. 

Ten years after the initial decision to implement NIDCAP, 
the Brest team hosted the Trainers meeting in Combrit, in the 
South of Brittany (October 2007). All attendees were provided 
a beautiful, quiet place to reflect and experience the special tastes 
and sounds of Brittany. Future challenges are to prepare a second 
NIDCAP trainer and to achieve NFI Nursery Certification.

The French NIDCAP Training Center Experience:
1998-2008: The first decade in Brittany

The Brest NIDCAP team: Sylvie Minguy, Isabelle Lohou, Blandine Le Guen, 
Jacques Sizun, Béatrice Kerleroux, Nathalie Ratynski, Catherine Delage 
with Professor Anand (University of Arkansas for Medical Sciences, Little 
Rock, Arkansas, USA), Céline Catelin (former fellow in Brest, France, now a 
neonatologist in Sherbrooke, Quebec, Canada), and Tiziana Testa (resident in 
Turin, Italy and Brest, France).

Nathalie Ratynski, MD and Jacques Sizun, MD



8  •  �008  •  Developmental Observer

The Neuroscience of Skin-to-Skin Contact
Nils Bergman, MB ChB, MPH, MD

For the last fifty years the focus 
of newborn care has been on 

survival, achieved through tech-
nological interventions, primarily 
focused on cardio-respiratory and 
nutritional support. The underly-
ing assumption has been that the 
development of the brain was 
primarily determined by genetic 
maturation over time, and did not 
really begin in earnest until some 
time after birth. The neurode-
velopmental needs of premature infants 
were therefore not considered, while their 
survival rate was improved. The quality of 
this survival has, however, not been good, 
and there is now increasing evidence that 
the brain requires care! “Developmental 
Care” is increasingly accepted as a good 
thing for newborns, premature or not. 
(While the NIDCAP approach provides 
very clear definitions about what the 
implementation of developmental care 
may mean, most people using this term 
are vague about what this actually entails). 
I will in this short article attempt to pro-
vide a simple but neuroscientifically based 
rationale for optimal neurodevelopment, 
central to which is maternal-infant skin-
to-skin contact. 

Brain development begins much 
earlier than previously recognized. At 20 
weeks post-menstrual age (PMA) all brain 
structures are in place and functional to 
some degree. Neurogenesis begins very 
soon after conception, but surprisingly, is 
essentially completed at 28 weeks PMA. 
The 100 billion neurons that have been 
formed have an inbuilt tendency to be 
eliminated; in order to survive they need 
to “fire and wire.”1 The “firing”comes 
from sensory stimulation, an obvious 
statement perhaps, but fundamentally 
important, and long neglected. For any 
specific pathway there is a salient stimu-

lus, as well as a critical period, or window 
of expectation. However, brain pathways 
are integrated circuits, and optimal neu-
rodevelopment requires integrated quality 
sensory stimulation.2 Absence of stimula-
tion during such periods results in failure 
of the pathway to wire.3 

In the uterine environment, some fe-
tal sensations are fully operational: sound, 
smell, and position. However, other fetal 
sensations are muted, sight in particular. 
In order to achieve firing and wiring of 
such pathways, REM sleep periods are 
responsible for achieving orchestrated 
“spontaneous synchronous firing” of all 
sensations.4 In past research, blocking 
such firing in visual pathways resulted 
in blindness, and resulted in the phrase: 
“Cells that fire together, wire together, 
and those that don’t, won’t.”1 But the 
“wiring” part of the brain connections are 
dependent on REM sleep in other ways 
also, and on the full sleep cycle.4 REM 
sleep cycles with four stages of non-REM 
sleep in approximately one hour rhythms, 
beginning in the last trimester, and is 
fully evident at term. Brain wiring occurs 
during this cycle in three distinct phases: 
acquisition during REM sleep or being 
awake, consolidation (also called pre-con-
solidation) during NREM stage 4, and 
memory formation (also called consolida-
tion) in the early phase of the next REM 
period. A full sleep cycle is required to 

achieve connected neuronal path-
ways. Disruption or deprivation 
of REM sleep increases neuronal 
cell death, and reduces final brain 
mass. 

Birth is the most critical event 
for all mammals. The organism 
has three major tasks to accom-
plish … transition, homeostasis 
and homeorhesis. In transition the 
organism must suddenly change 
its entire cardio-respiratory func-

tionality, while at the same time maintain-
ing its homeostasis (i.e., its internal total 
metabolic balance). Homeorhesis (Greek 
for “similar flow”) is more demanding 
than just balance in a stable state; the or-
ganism is also developing along a trajecto-
ry, which it must maintain. It is the brain’s 
developmental trajectory which is para-
mount. In the past, the human newborn 
was regarded as helpless and incompetent. 
There is in fact astonishing neurological 
competence wired into the fetal brain in 
preparation for birth. Neither the compe-
tence, nor the conditions for it, have been 
well understood.

The word “critical period” is not well 
accepted by the medical profession, but 
birth is undoubtedly a “critical event.” 
The competence of the mammalian new-
born is dependent on its brain circuitry. 
Brain function is dependent on appropri-
ate sensory stimulations. Throughout evo-
lution, this was provided by the maternal 
milieu. Every mammal studied attests to 
“highly conserved perinatal behaviours,”5 
in which the newborn plays the primary 
role in initiation and maintenance, with 
subsequent elicited responses from moth-
er. It is mother’s presence and the stimula-
tions that she provides which are essential 
for the behaviours which lead to success-
ful transition and subsequent adaptation 
to extra-uterine life.6 That adaptation will 



Developmental Observer  •  �008  •  �  

immediately require the continued provi-
sion of “basic biological needs”of warmth, 
nutrition and protection. It may be useful 
to distinguish that these are needs for the 
body, as opposed to the brain which needs 
stimulation. Maternal-infant togetherness 
ensures provision of warmth, nutrition 
and of protection. The critical behaviour 
that brings these together is breastfeeding. 
Breastfeeding is at the same time an um-
brella providing every sensory modality 
to the brain’s developing pathways.7 Thus 
the mother’s presence provides both basic 
biological and neurological requirements. 

Primates deliver young which are bio-
logically immature, and maternal-infant 
skin-to-skin contact is the rule, not least 
due to thermal requirements. Skin-to-
skin contact stimulates neural pathways 
that reach the amygdala directly (along 
with smell), without passing through 
higher brain centres.8 These may be seen 
as primary regulating sensations, decribed 
under the “continuity hypothesis.”9 The 
amygdala is described by le Doux as being 
at the core of the “emotional brain.”10 
From the amygdala autonomic regulation 
of all body systems is achieved (down-
ward function), and approximately 200 
randomized controlled trials on skin-to-
skin contact on premature human infants 
attest to this regulation. From the amyg-
dala, key pathways fire and wire to higher 
brain centers (upward). One of these is 
the amygdala prefrontoorbital cortical 
pathway,8 which links the emotional core 
of the brain to the “behavioural activation 
system” of the brain,11 which determines 
future “approach versus avoid” tendency. 
This pathway is specifically “fired” by 
skin-to-skin contact that can later be mea-
sured in right frontal EEG assymmetry, 
a measure of physiological and psycho-
logical resilience.12, 13 This skin-to-skin 
contact may be at the core of subsequent 
attachment behaviour and also has pro-
found effects on regulating the sleep cycle, 
ensuring adequate deep sleep for NREM-
4 and spaced periods of REM.14 Thus the 

effect of maternal-infant skin-to-skin con-
tact is one of “dual coding,”15 achieving 
simultaneous physiological regulation and 
emotional (or psychological) attachment. 
It may be the basic building block of fu-
ture capacity to achieve “stability through 
change,” Schore’s definition of health.8 

Maternal-infant separation signifi-
cantly disrupts the processes described 
above. Sleep cycling is absent during 
incubator care. But, since separation is ac-
cepted as “normal,” the physiological state 
it produces is regarded as normal. In fact, 
the response of the amygdala is to ensure 
a survival state, homeostasis without ho-
meorhesis. Schore describes this in adults 
as “hyperarousal dissociation.”3 In early 
primate research, this was called “protest 
despair” in separated infants.16 That this 
applies to the human newborn needs to 
be stated, even if obvious. 

Neuro-cognitive development (as 
in Bayley,17 or IQ) has been the basis 
for measuring the long term impact of 
modern newborn care, specifically in 
premature infants. I would suggest on the 
basis of this neuroscience that these are 
invalid measures. The processes that are 

disrupted are regulation and attachment, 
and the latter leads primarily to emotional 
and social development, not cognitive. 
Emotional and social intelligence would 
be valid measures of developmental care.15 

Social and emotional intelligences 
do in fact provide a platform for higher 
cognitive functions, and cognitive func-
tions almost certainly are improved, 
albeit indirectly. But “IQ” is a complex 
and diffuse concept, and may be seen as 
a remote downstream effect. There is no 
direct cause-effect between these intel-
ligences and cognitive capacity. High IQ 
may even be a compensatory mechanism 
in some emotionally deprived individu-
als. From an evolutionary perspective, the 
primary objective of the primate perinatal 
period was to achive emotional and social 
competence. 

Optimal neurodevelopment requires 
that our care and technology is applied 
(and adapted as necessary) so as to ensure 
there is no separation of the mother-in-
fant dyad. Maternal-infant separation is, 
unfortunately, the norm in our health sys-
tem. Maternal-infant skin-to-skin contact, 
not separation, is the norm of our biology. 

References:
1. Shatz CJ. The developing brain. Sci Am 1992 Septem-

ber;267(3):60-7.
2. McCain HN, Mustard JF. Neuroscience and early child 

development. In: Reversing the real brain drain: Early 
Years Study.  25-52. 1999. Toronto, ON, Canada, Ontario 
Children’s Secretariat. Ref Type: Generic.

3. Schore AN. The effects of early relational trauma on right 
brain development, affect regulation, and infant mental 
health. Infant Mental Health Journal. 2001; 22 (1-2): 
201-69.

4. Graven S. Sleep and Brain Development. Clinics in 
Perinatology. 2006; 33: 693-706.

5. Keverne EB, Kendrick KM. Maternal behaviour in sheep 
and its neuroendocrine regulation. Acta Paediatr Suppl. 
1994 June; 397: 47-56.

6. Alberts JR. Learning as adaptation of the infant. Acta Pae-
diatrica (Oslo, Norway: 1992). 1994; Suppl 397: 77-85.

7. Gallagher W. Motherless Child. The Sciences. July/Au-
gust, 12-15. 1992. Ref Type: Generic.

8. Schore AN. Effects of a secure attachment relationship 
on right brain development, affect regulation, and infant 
mental health. Infant Mental Health Journal. 2001; 22 
(1-2): 7-66.

9. Anderson GC. Touch and the kangaroo care method. In: 
Field T, editor. Touch in Early Development.Hillsdale: L 
Earlbaum; 1995. p. 34-51.

10. Le Doux J. The Emotional Brain: The mysterious under-
pinnings of emotional life. New York: Simon & Schuster 
Paperbacks; 1996.

11. Amodio DM, Master SL, Yee CM, Taylor SE. Neurocog-
nitive components of the behavioral inhibition and activa-
tion systems: Implications fdor theories of self-regulation. 
Psychophysiology. 2008; 45: 1-11.

12. Diego MA, Field T, Jones NA, Hernandez-Reif M. With-
drawn and intrusive maternal interaction style and infant 
frontal EEG asymmetry shifts in infants of depressed and 
non-depressed mothers. Infant Behavior & Development. 
2006; 29 (2): 220-9.

13. Jones NA, McFall BA, Diego MA. Patterns of brain 
electrical activity in infants of depressed mothers who 
breastfeed and bottle feed: the mediating role of infant 
temperament. Biological Psychology. 2004; 67(1/2):  
103-24.

14. Ludington-Hoe SM, Johnson MW, Morgan K, Lewis T, 
Gutman J, Wilson PD et al. Neurophysiologic Assessment 
of Neonatal Sleep Organization: Preliminary Results of a 
Randomized, Controlled Trial of Skin Contact With Pre-
term Infants. Journal of the American Academy of Child 
& Adolescent Psychiatry. 2006; 45 (12): 1455.

15. Greenspan SI, Shanker SG, Phil D. The First Idea. Da 
Capo Press; 2006.

16. Harlow HF, Suomi SJ. Social Recovery by Isolation-Rea-
red Monkeys. Proceedings of the National Academy of 
Sciences. 1971; 68 (7): 1534-8.

17. Bayley N. Bayley Scales of Infant Development-II, The 
Psychological Corporation. 2001.



Kangaroo Mother Care
I don’t remember when I first heard about “kangaroo care.” I had worked in 
the intensive care nursery since 1988, but my first encounter with the term 
“kangaroo care” was in the articles that I read during my graduate nursing 
program in 1992. What struck me was not only how simple the concept was, 
but also how it was discovered. 

Kangaroo care developed out of necessity in a country where 

the ability to care for all the premature infants in the hos-

pital was hampered by lack of equipment. It was a measure that, 

although carefully and thoughtfully accomplished based on what 

is “natural,” was nevertheless born from a desperate need, not a 

result of controlled research. Since then research with kangaroo 

care has looked at a variety of aspects, from documenting the 

safety for high risk infants engaged in kangaroo care, to examin-

ing the emotional benefits to mothers who participate, to iden-

tifying the physiological processes and mechanisms of kangaroo 

care that appear to facilitate development of the infant.1,2 There 

is still much to research and to understand. In the NICU, we 

also encourage fathers to participate and recognize how beneficial 

this kind of holding is to fathers and their infants. However, the 

initial concept, perhaps more accurately called “kangaroo mother 

care,” where the mother is the source of continuous warmth and 

nourishment to the infant, is the subject of this reflection.

Many people object to the term “kangaroo care,” saying that 

it denigrates the unique humanness of the infant/parent relation-

ship. That it makes light of, or makes too “cute” an activity that 

has profound emotional and physical consequences for both 

parties. Perhaps because I am married to an evolutionary ecolo-

gist, I see this reference to our mammalian heritage as natural, 

not offensive. To me, the term also reflects an accurate perspec-

tive of this activity. Anthropologists and biologists recognize the 

developmental phases that mammalian species move through in 

their transition from infant to adulthood, which can be divided 

into: the uterine phase, the breast phase and the social/community 

phase.3-5 Human infants are an unusually dependent mammalian 

species, born before they are well developed. This is thought to 

be an evolutionary compromise because a more mature brain 

would not be able to be delivered in the woman whose pelvis has 

adjusted to bi-pedalism. So the infant is born while still imma-

ture and must spend significant time with the mother staying 

warm and being provided nutrition while they complete the 

developmental phases that in other more precocial species are ac-

complished in utero. Like marsupials, who very competently find 

their way to their mother’s teat, and bask in the warmth of her 

pouch, so the human infant is very competent to continue physi-

cal, cognitive and social development while being supported by 

the mother during extensive bodily contact. 

This extensive “breast phase” is still experienced in many 

non-technological communities, but there has been a cultural 

shift in industrial societies where the “breast phase” is shortened 

or non-existent. While physical survival is possible without the 

mother’s milk and warmth, there can be severe emotional and 

social consequences, some of which we are just beginning to rec-

ognize.6 Technology in the NICU has increasingly become more 

sophisticated in supporting the physical well being of premature 

infants. Can we now begin to acknowledge that these vulnerable 

infants are the ones that need the most contact with their moth-

er? Kangaroo mother care, where the mother serves as the source 

of warmth and nutrition in a hospital setting, has been successful 

in promoting positive outcomes of low birthweight infants in a 

number of countries where options are limited, although larger, 

randomized studies are still needed to document these effects.7,8

Perhaps part of our dilemma in the United States is our 

inability to see mother and child as an inseparable dyad, in our 

failure to acknowledge this “breast” phase of development. Our 

workplace culture has long been a source of frustration for those 

N I D C A P  r e F l e C T I O N s

Jean Powlesland, RN, MS

10  •  �008  •  Developmental Observer



Developmental Observer  •  �008  •  11  

women who wish to ensure their employment, yet still meet the 

needs of their small, nursing infants. Frequently, this dichotomy 

occurs much earlier. For the healthy, newly delivered infant, the 

mother and infant stay together and never need to be separated. 

If the mother goes home from the hospital, and the baby must 

stay behind, our expectations change. Healthcare systems do not 

acknowledge the unhealthiness of the separation, and often it is 

the most at risk families that cannot manage to overcome it. We 

have evidence that kangaroo care will improve the development 

of the premature infant and may improve the parent/infant rela-

tionship, and that separation of mother and child may be dam-

aging.1,2, 9,10,11 So why is there so little support for parents to be 

continuously available to their hospitalized infants? A neighbor-

ing hospital has a very aggressive breastfeeding policy that makes 

it a practice of informing the mothers of premature infants that 

they have no choice but to provide milk for their infants, because 

it is clearly the best nutritional option. Should we make kangaroo 

care mandatory for premature infants who are in the process of 

forming the foundation of their emotional and cognitive lives? 

I am cast back to when my daughter, Miriam, was born seven 

weeks prematurely many years ago. I was admitted for severe 

epigastric pain and very suddenly needed an emergency C-sec-

tion. I became an educational object for the obstetric residents, 

as they were brought by in groups and lectured on the relatively 

newly named “HELLP” syndrome that I had. Miriam came into 

the world a few minutes shy of Christmas Eve, crying strongly 

as she was handed to the pediatrician, her arms and legs wav-

ing frantically in the air. As she was weighed and examined, her 

crying subsided into a rhythmic grunting, which meant that she 

was destined for the special care nursery. My arms were strapped 

down to the operating room table, and just before Miriam was 

transferred out, she was brought close to my face, where I could 

only awkwardly nuzzle her head with my nose and cheek. 

Miriam was in the special care nursery for only a few hours. 

I, however, stayed in labor and delivery for a day and a half, 

heavily sedated with magnesium; my arms oozing blood from 

the frequent blood draws to monitor my falling blood counts. It 

is only in hindsight that I realize how traumatizing this experi-

ence was, and how battered and bruised I felt, both emotionally 

and physically. My pregnancy had been disrupted, and I had 

become truly “sick” and afraid of my body. The first time I felt 

at peace was when Miriam was brought to me as she was being 

transferred from the special care to the normal newborn nursery. 

She was placed on my chest, and though my magnesium intoxi-

cated brain wasn’t processing all that the nurse was telling me, 

what came through was the warmth of her skin, the feel of her 

breath as her body rose and fell, and her little squeaks, squeals 

and squirms as she settled down on me. The NICU nurse in me 

was trying hard to think of the questions I should be asking, but 

my sedated nervous system could not formulate them. However, 

the mother in me was reassured, feeling through my skin and the 

core of my being that my baby was okay.

Since then, I realize how much that primal reassurance 

meant to me, and I believe that babies too need that comfort 

from closeness with their mother. This contact is the closest the 

premature infant can get to regain the “uterine phase” while 

transitioning to the “breast phase.” This is what is expected, and 

what is needed. As NICU professionals, we need to explore ways 

to make it an expectation of care for all premature infants.

References:
1. Dodd VL. Implications of Kangaroo Care for growth and development in preterm infants. 

Journal of obstetric, gynecologic and neonatal nursing 2005; 34 (2): 218-232.
2. Browne, JV. Early relationship environments: physiology of skin-to-skin contact for parents 

and their preterm infants. Clinics in Perinatology 2004; 31: 287-298.
3. Hofer MA. Early social relationships: A psychobiologist’s view. Child Development 1987; 

58: 633-647.
4. McKenna J, Ball H, Gettler L. Mother-infant cosleeping, breastfeeding and sudden infant 

death syndrome: what biological anthropology has discovered about normal infant sleep and 
pediatric sleep medicine. -  American Journal of Physical Anthropology 2007; 134(S45): 
133-61. 

5. Als H, Gilkerson L. The role of relationship-based developmentally supportive newborn 
intensive care in strengthening outcome of preterm infants. Seminars in Perinatology 1997; 
21 (3) 178-189.

6. Schore AN. Attachment and the regulation of the right brain. Attachment and Human 
Development 2000; 2 (1): 23-47.

7. Cattaneo A, Davanzo R, Bergman N, Charpak N. Kangaroo mother care in low income 
countries. International Network in Kangaroo Mother Care. Journal of Tropical Pediatrics 
1998; 44: 279-295.

8. Conde-Agudelo A, Daiz-Rosello JL, Belizan JM. Kangaroo mother care to reduce morbidity 
and mortality in low birthweight infants. Cochrane Database of Systematic Reviews 2008.

9. Tessier R, Cristo M, Velez S, Giron M, Ruiz-Palaez JG, Charpak Y, Charpak N. Kangaroo 
Mother Care and the Bonding Hypothesis. Pediatrics 1998; 102: e17.

10. Hofer MA. Hidden Regulators in attachment, separation and loss. Monographs of the 
Society for Research in Child Development 1994; 59: 192-207.

11. Feldman R, Eidelman AI, Sirota L, Weller A. Comparison of skin-to-skin (kangaroo) and 
traditional care: parenting outcomes and preterm infant development. Pediatrics 2002; 110: 
16-26.



1�  •  �008  •  Developmental Observer

N I D C A P  P r O F I l e

Dorothy Vittner, RN, MSN and Joy V. Browne, PhD, CNS

There could be no better spokespeople for parents than 
these two unique and especially talented people. Both 

Vicky and Tracy have had up close and personal experiences 
with their children and grandchildren in NICUs. They are 
each national leaders in the field of early intervention and have 
made their mark on education and advocacy and sensitive care- 
giving for infants and children who interface with the health 
care system. Their voices and contributions on the NFI board 
will be critical to the future directions that the NFI pursues. 

Vicky Youcha is currently leading a multimedia project 
focused on preventing, treating, and living with traumatic brain 
injury, for a public broadcasting station in the Washington D.C. 
area.  She compares her present efforts with the technical world 
of the NICU where life and death decisions may be made in an 
instant often engulfed by emotions.  

Vicky is an experienced “two timer” in the NICU.  Her 
daughter and grandson both began their lives in an NICU. 
Despite her role as Developmental Specialist and vast knowledge 
of parent-infant development and its importance, the NICU was 
a difficult place to navigate. She continually uses her own past 
experiences to support and strengthen her daughter’s relationship 
with her grandson by encouraging techniques such as kangaroo 
care holding. She expresses with passion how the connections 
developed during that critical period in the intensive care nursery 
have strengthened attachment between her daughter, son-in-law 
and her grandson. Vicky recognizes the need to continuously 
support “parents to be parents” while their infants are in the 
NICU and articulates her perceptions of how parenting can 
have a direct impact on improving the outcomes of infants born 
prematurely. 

Vicky’s first encounter with NIDCAP came when Dr. 
Heidelise Als presented at George Washington University 
(GWU) in the early 1980’s about the infant’s experience and the 
impact the sensory environment had on the developing baby. 
These presentations validated her own thoughts as she parented 
her daughter in the NICU. This encounter strengthened her  

resolve to support families in developing strong relationships 
with their infants and to develop systems to support families to 
be an integral part of the health care team. 

As a professional, Vicky has had extensive knowledge and 
experience with early childhood development and special educa-
tion. She has had a long history as a Developmental Specialist, 
as well as directing an early intervention program at GWU. She 
received many national grants focused on including children 
with special needs in regular early childhood settings. Vicky has 
published numerous articles on national policy recommenda-
tions and guidelines for Individualized Family Service Plans and 
Implementation Resources along with the Training Manual for 
Head Start Regulations for Children with Disabilities. In her 
work at Zero To Three, Vicky directed several projects. One 
was aimed at helping juvenile and family court judges improve 
outcomes for infants and toddlers. Another was shepherding the 
Leaders for the 21st Century program for Zero to Three Fellows, 
where she encouraged and exemplified leadership in the infant 
and toddler field.

Vicky is  known to take adventure trips to remote areas to 
kayak and ski. She is a tiny but powerful force to be reckoned 
with, and is known to take on Mother Nature by storm, and 
with a smile. She also cuts a mean rug with swing dancing. But 
her passion is babies—not only her grandson, but also all babies 
who come to the world with special needs. Her passion and 
treasure chest of knowledge about infants and their families spill 
out with each story she shares.  

Tracy Price-Johnson is an accomplished public speaker, educa-
tor and advocate for families. Her daughter Hayley was born and 
cared for in a NICU for her first three and a half months after her 
birth and developed significant disabilities. As Hayley grew older, 
Tracy used all her professional and newly found parenting skills 
to increase public awareness and advocacy in support of family 
centered care principles for infants and children in the health and 
education systems. Tracy continues to teach at the University of 
Colorado, Denver School of Medicine, JFK Partners University 

Continued on page 18

Vicky Youcha, EdD, and Tracy Price-Johnson, MA
Who can better advise professionals in the NICU than  
people who have experienced the ups and downs of the NICU 
roller coaster ride? The NIDCAP Federation International 
(NFI) recognizes the unique contributions that experienced  
parents can provide and has recently added two new family 
members, Vicky Youcha and Tracy Price-Johnson, to the  
Board of Directors. 



Developmental Observer  •  �008  •  1�  

s u P P O r T I N G  FA M I l I e s

Melissa R. Johnson, PhD

Attachment Theory: A Natural 
Fit with NIDCAP Practice

A  key goal in the work of all NIDCAP professionals is sup-
porting the relationship between parents and their infant. 

The synactive theory1 provides a powerful theoretical basis  
for understanding the infant in the context of the unexpected 
environment of the NICU. Many NIDCAP practitioners have 
found attachment theory to be another valuable resource. Like the 
synactive theory, it combines rich and complex 
theory with a large body of empirical support.2 

These two theories also have in common 
their deeply humanistic worldview and a com-
mitment to relationships as a core value in all 
clinical work. They are mutually supportive 
in guiding work with parents in the NICU, 
and in focusing on parental relationships 
with their infants as well as with their infants’ 
caregivers. In addition, these theories share a 
firm grounding in ethology and evolutionary 
biology1, 3 and a profound respect for the im-
portance of patient, naturalistic observation of 
infants in guiding theory and practice.4,6 They 
also offer a framework for understanding how the physical and 
interpersonal environment influences the immature developing 
human brain, shaping its structure and function, and thus help 
to determine the individual’s future.7, 8

An understanding of attachment theory can support the 
clinical goals of NIDCAP developmental practitioners and guide 
interactions in the NICU in a number of ways. First, it is impor-
tant to note that attachment relationships include those between 
parents and caregivers as well as those between children and 
parents. Bowlby 3 and subsequent researchers are clear that at-
tachment behaviors, involving the seeking of proximity to figures 
seen as stronger and able to help in stressful situations, continue 
throughout life. As parents strive to cope successfully with the 
overwhelming emotional and physical challenges of having an 
infant in the NICU, staff who are knowledgeable and powerful 
in this environment may be seen as attachment figures able to 
provide comfort and safety to parents. Parents who receive this 
kind of support may then be able to rally their own strengths on 
behalf of their infants. Staff who understand this role, and are 
comfortable with meeting the attachment needs of new parents 
dealing with the crisis of preterm birth, have a powerful op-
portunity to facilitate the parents’ ability to develop the strong 
attachment relationships with their infant that will help ensure 

their optimal outcome. This may be seen clinically in situations 
where parents are perceived as being needy, lacking trust in staff, 
or appearing fearful in handling their infant. 

In their role of supporting the developing parent-infant rela-
tionship it is extremely important that staff: 1) are aware of their 
own feelings toward the infant, and strive to facilitate the rela-
tionship between the parent and the infant, rather than allow-
ing their own empathetic connection to the infant supplant the 
parents’ primary relationship to their child; and 2) seek reflective 
guidance from a psychiatrist, psychologist, or a consultant with 
a clinical mental health background, an essential support as the 

staff strive to accomplish these goals. With 
the reflective guidance and support of a clini-
cal mental health professional, nurses or other 
staff may begin to assess and address the un-
derlying concerns haunting the parent, as well 
as the nature of the parent’s past and present 
attachment relationships. This may provide 
the kind of support that meets the parent’s 
appropriate needs for attachment figures in 
this emergency. In practice, this appears as: 
verbal and non-verbal acceptance of needs; 
offering the time and interest to share and 
process the level of disclosure comfortable for 
the parent; joining with the parents in their 

efforts to understand their infant’s needs (e.g., close observation 
of the infant’s behavioral signals); supporting the parents in their 
role of providing care to their infant (e.g., skin-to-skin holding, 
breastfeeding); and facilitating their active participation in the 
decision-making process. This effort flows naturally into support 
of the parent-child relationship. The parent’s drive to establish 
and maintain physical and emotional closeness with the infant, 
and the infant’s increasingly competent efforts to orient toward 
the parent’s voice, body and face, are facilitated when the parent 
feels secure and connected themselves.

When parents worry aloud, as some do, whether they are 
“bonded” with their infants, attachment concepts suggest several 
helpful responses. For example, one can honestly assure parents 
that the very fact that they are asking that question is an indicator 
of developing attachment. Some parents may think and worry 
about their infant when they are not in the nursery, or they may 
think that it “doesn’t feel right” to leave their infant behind when 
they go home. Many parents may experience these feelings, which 
again are indicators of parental attachment with the infant, pre-
dicting future blossoming of infant attachment to the parent.

Specific practices and examples discussed above, however, 
are less important than integrating an understanding of the 
principles of attachment into the world view and underlying 

Continued on page 18



1�  •  �008  •  Developmental Observer

Inga Warren, Dip COT, MSc

C u r r e N T  D e V e l O P M e N TA l  r e s e A r C h

Breastfeeding & Development

There is growing evidence that breastfeeding enhances neu-
rodevelopment. Claims of benefits for breastfeeding have 

often been disputed on the grounds that mothers from more 
privileged socioeconomic backgrounds are more likely to breast-
feed, thus skewing the outcomes. A cluster randomization trial1 
involving 31 Belarussian maternity hospitals, enrolled 17,046 
healthy breastfeeding infants, and included an intervention  
group that received breastfeeding promotion modeled on the 
Baby Friendly Initiative.2 Breastfeeding uptake was significantly 
higher in the intervention group compared to the group where 
mothers were left to follow their own inclination, as were scores 
on the Wechsler Abbreviated Scales of Intelligence3 at six and 
one-half years of age. Teachers also evaluated academic achieve-
ments more highly in the intervention group. The randomiza-
tion and sheer size of this study strengthen arguments in support 
of an independent effect of breastfeeding on development. 
Whether or not this is due to the ingestion of breastmilk or 
increased closeness between mother and infant would be difficult 
to demonstrate. 

Much of the evidence for enhanced neurodevelopment re-
lates to term infants but Vohr et al.4 followed up 1035 extremely 
low birth weight infants on 15 sites to 18 months corrected age 
and with multivariate analysis, adjusting for confounders such 
as socioeconomic status, confirmed a significant independent 
association of breastmilk on the Bayley Scales of Infant Develop-
ment-II5 (i.e., Mental, Psychomotor and Behavior Rating Scales). 
The more breastmilk the infants ingested the stronger the as-
sociation.  Feldman and Eidelman6 found a direct association 
between breastmilk and neurobehavioral organization in preterm 
infants and postulated that there may be a link between maternal 
depression, lower quantities of breastmilk and poorer develop-
mental outcomes. 

The health benefits of breastmilk for preterm infants are well 
established and include protection from necrotizing enterocolitis 
(NEC),7 which may require intensive care treatment and surgery, 
thus exposing the infant to the developmental risks associated 
with severe illness, restricted nutrition and possibly the iatrogen-
ic effects of intensive care. Avoiding NEC is therefore likely to 
reduce the risk of negative developmental outcomes. Breastfeed-
ing has well known health benefits for mothers too. 

While breastfeeding rates for preterm infants admitted to 
newborn intensive care units are often assumed to be low in 
comparison to those for the healthy term newborns, this may 
be deceiving. A study of the Pregnancy Risk Assessment and 
Monitoring System (PRAMS)8 in 27 US states over four years 
found that when the data was adjusted for multiple confounders, 
such as maternal race, age, education and antenatal care; NICU 
admission actually appeared to have a beneficial effect on breast-
feeding.9 Anecdotal reports from NIDCAP Training Centers 
suggest that a higher proportion of infants may be discharged 

breastfeeding from the newborn intensive care unit, than from 
the maternity unit in the same hospital.  Warren et al.10 found 
that when breastfeeding support was combined with develop-
mental care, breastfeeding increased considerably; at discharge 
83% were breastmilk fed although 8% were taking breastmilk 
from bottle or cup; at that time the maternity unit was achieving 
similar rates to the national average of 65%. 

Bottle feeding may be offered on the assumption that it will 
accelerate discharge. Profit  et al.11 reports a mean age on dis-
charge from the  newborn intensive care unit of 36.3 weeks cor-
rected age for infants born between 30 and 35 weeks gestation 
in the United Kingdom (1998-99) and 35.9 weeks in California 
(2001-2003). Nyqvist12 described breastfeeding development 
in a diverse but small (n=15) number of much younger babies 
(born between 26 and 31 weeks of gestational age) in a Swedish 
nursery that provided skilled breastfeeding support, facilities for 
rooming in and an individualized developmental care approach. 
She reports a median age of 35.4 weeks corrected age at discharge 
from hospital to home. Warren et al.10 in a retrospective study 
collected data on all infants born in one year before 35 weeks 
gestational age (n=60; range 24 – 34 gestational age), regardless of 
complications, in a nursery that favored an individualized devel-
opmental care approach. Fully breastfed and other breastmilk fed 
babies were discharged at a median age of 36 weeks. These two 
studies suggest that the potential for lactation support combined 
with developmental care to facilitate early discharge from hospital 
for very preterm infants is worth further investigation.  

Newborn intensive care units often offer bottles before the 
breast and may suggest that this should begin at around 33-34 
weeks when maturation of oral motor skills makes suck feeding 
relatively safe. Nyqvist12 suggests that breastfeeding can be pre-
sented to the infant much earlier, provided appropriate support 
is offered. She describes breastfeeding behavior in infants born 
between 26-31 weeks of gestational age, and reports that infants 
as young as 29 weeks were rooting and that by 31 - 32 weeks 
corrected gestational age some of these infants were competently 
latching on, with long sucking bursts and repeated swallowing.

A common misconception holding back breastfeeding is 
the idea that women will feel pressurized and stressed by this 
expectation. Sisk et al.13 found that lactation counseling given 
to mothers of very low birth weight babies increased lactation 
initiation and breastfeeding without increasing maternal stress 
and anxiety. Kavanagh et al.14 used semi-structured interviews 
with mothers of preterm infants to explore their perceptions 
of breastfeeding. These mothers described specific emotional 
advantages that they related to breastfeeding, indicating that the 
rewards were worth the effort. 

Clearly, the research cited within this article demonstrates 
the importance of breastfeeding support within a developmental 
care program because it may enhance developmental outcomes, 
promote early discharge, and be an advantage for mothers as well 
as their infants.

References on page 18



D e V e l O P M e N TA l  r e s O u r C e s

Kathleen A. VandenBerg, PhD

Developmental Observer  •  �008  •  1�  

This column provides our readers  
with current information regarding 
developmental resources related to  
NIDCAP.

Articles

1.  Als H & Butler S. Newborn 
individualized developmental care 
and assessment program (NIDCAP): 
Changing the future for infants and 
families in intensive and special care 
nurseries. Early Childhood Services. 
2008; 2 (1): 1-19.

2.  Lawhon g & Hedlund RE. Newborn 
individualized developmental care 
and assessment program (NIDCAP) 
training and education. Journal of 
Perinatal and Neonatal Nursing. 2008; 
22 (2): 133-144.

3.  Smith KM, Butler S & Als H. 
Newborn individualized developmental 
care and assessment program 
(NIDCAP): Changing the future for 
infants and families in intensive and 
special care nurseries. Italian Journal  
of Pediatrics. 2007. 

Book Chapters

Als H, & Butler S. Screening of newborn 
and maternal wellbeing.  In: Haith M & 
Benson J (eds). Encyclopedia of Infant and 
Early Childhood Development. Amsterdam: 
Elsevier. 2008; 3: 66-78.  

Books

1. Disorders of Behavioral and Emotional 
Regulation in the First Years of Life, Early 
Risks and Intervention in the Developing 
Parent-Infant Relationship.

 Mechtild Papousek, Michael Schieche, 
and Harald Wurmser, Editors. Trans-
lated by Kenneth Kronenberg. 2007.  
Zero To Three.

 Recently translated, this book provides 
an in depth overview of emotional 
regulation from birth to three years 
of age. A thorough review of excessive 
crying, sleep disorders, feeding disorders 
and behavioral difficulties is provided.  

Evaluation of behaviors and therapeutic 
approaches are discussed in detailed case 
studies. 346 pages. $49.95.

2. Early Development and the Brain: Teach-
ing Resources for Educators.

 Linda Gilkerson and Rebecca Klein, 
Editors. 2008. Zero To Three.

 This is a nine-unit curriculum that 
translates scientific research into practi-
cal suggestions to help early childhood 
professionals understand the link 
between caregiving and brain develop-
ment. Topics include brain structure 
and function, language, and the effects 
of stress and maternal drug use on brain 
development. CD-ROM includes Pow-
erPointTM slides and course handouts. 
794 pages. $359.99.

Conferences 

1. Developmental Interventions in 
Neonatal Care Conference: October 
1-4, 2008, Denver, Colorado, USA. 
Sponsored by Contemporary Forums. 
The Preconference (October 1) offers 
presentations on individualized devel-
opmental care designed to highlight 
developmental intervention practices. 
Topics include Essential Concepts In 
Developmental Care, Management 
of Infant Behaviors, Development of 
Feeding Skills in Preterm and Term 
Infants, and the Role of Movement and 
Posture in  Promoting Physiology. The 
Main Conference (October 2-4) offers 
plenaries and concurrent sessions cover-
ing current research updates, practical 
strategies for providing effective devel-
opmental care and applicable medical 
information.  For more information, 
please visit the conference website at: 
www.contemporaryforums.com.

2. Infant Development in Neonatal 
Intensive Care (IDNIC): “Closing the 
gap between research and practices.” 
December 12-13, 2008, Paris, France. 
Although the quantity of research on 
positive impact of non-pharmacologi-
cal strategies on outcome in preterm 
neonates has expanded, the gap between 
research and practice remains wide 

(pain control, early intervention, breast 
milk). The goals of this conference are 
to explore reasons for this gap and to 
offer strategies for bridging it.  Please 
visit the conference website at: www.
info-congres.com.  

3. The 22nd Annual Gravens Conference 
on the Physical and Developmental 
Environment of the High Risk Infant: 
January 21-24, 2009, Clearwater 
Beach, Florida, USA.  This conference 
focuses on developmental care and the 
impact of the physical environment on 
premature and high-risk babies. This 
year’s focus is on the psychological and 
physiological interactions in the NICU. 
The March of Dimes Family Support 
Summit, which will address current 
application of family support services 
in NICUs, will be held in conjunction 
with the Gravens meeting. For more 
information, please visit the conference 
website at: www.cme.hsc.usf.edu/hri09.

4. The 4th International Conference on 
Brain Monitoring and Neuroprotec-
tion in the Newborn: February 20-22, 
2009, Orlando, Florida, USA. This 
conference focuses on new strategies 
and technology in the assessment of 
early brain function. It is intended to 
bring the most current research and ap-
plication in clinical practice to a forum 
where the results can be translated for 
use by clinicians. For more information, 
please visit the conference website at: 
www.cme.hsc.usf.edu/brain09.

5. The Fragile Infant Feeding Insti-
tute (FIFI): Spring of 2009 (specific 
date and site to be determined). This 
conference focuses on the development 
of feeding in preterm and high-risk 
infants. Using the NIDCAP model, this 
four and a half-day conference teaches 
evidence based interventions using in-
dividualized assessment and supportive 
strategies applied to clinical practice for 
in-hospital and community profession-
als. To have your name placed on a dis-
tribution list for first come-first served 
selection, please contact Joy Browne, 
PhD at: browne.joy@tchden.org.  
 



1�  •  �008  •  Developmental Observer

The Newborn Individualized Developmental Care and Assessment Program (NIDCAP)

The Newborn Individualized Developmental Care and Assessment Program (NIDCAP), originated 

in 1984 by Heidelise Als, PhD, is a developmental, family centered, and evidence-based care 

approach. NIDCAP focuses on adapting the newborn intensive care nursery, including all care and 

treatment and the physical environment, to the unique neurodevelopmental strengths and goals  

of each high risk newborn and his or her family, the infant’s most important nurturers and 

supporters. For a complete description of training centers and the training process please visit  

our website: www.nidcap.com.

The Assessment of Preterm Infants’ Behavior (APIB) 

The Assessment of Preterm Infants’ Behavior (APIB) is a comprehensive and systematic neurobe-

havioral assessment of preterm and fullterm newborns developed by Heidelise Als, PhD and her 

colleagues (published in 1982, see www.nidcap.com for details). The APIB requires in-depth  

training and provides a highly valuable resource in support of developmental care provision by  

professionals and families.

6. Multidisciplinary Family Centered 
Care Conference:  The Fourth Inter-
national Conference on Patient and 
Family Centered Care: August 17-19, 
2009, Marriott Hotel Downtown, 
Philadelphia, Pennsylvania, USA. 
This conference is sponsored by the 
Institute for Family Centered Care 
and will address innovative programs 
dedicated to promoting partnerships 
between patients, family and health 
care professionals and health care 
systems. For more information, please 
visit the conference website at: www.
lstreeter@iffcc.org.

Recognition of Developmental 
Care Competency

National Association Neonatal  
Nurses Advanced Competency in  
Developmental Care
The purpose of this Program is to pro-
mote excellence in professionalism by 
acknowledging the healthcare providers 
who have acquired a body of knowledge 
and expertise in the field of providing 
developmental care. Please see: www.
nann.org/-8acdc.html.

We invite you to send in information that you may encounter, such 

as upcoming conferences, websites, books, journals, articles, 

videos, etc., that may be shared with our readers. Please send items 

for inclusion in the Developmental Observer to Diane Ballweg at: 

developmentalobserver@nidcap.org.

From the Editors

We invite you to write us with your 
comments regarding the content  
of any of the columns presented  
in this newsletter. We are also  
interested in any suggestions that  
you have with regard to future  
topics that you would like to see  
addressed in the Developmental  
Observer. Please contact us at:  
developmentalobserver@nidcap.org.

Developmentally yours,

Rodd Hedlund, MEd  
Senior editor 

Deborah Buehler, PhD  
ASSociAte editor

gretchen Lawhon, RN, PhD  
ASSociAte editor

Sandra Kosta, BA  
text editor

D e V e l O P M e N TA l  r e s O u r C e s



Developmental Observer  •  �008  •  1�  

Dear Editors,
I have completed my thorough 

reading of the recent DO and wanted 
to tell you all how wonderful I thought 
it was. The Advanced Practicum piece is 
excellent and will guide all of us. 

I am sure that very soon we will be 
wondering how we lived without it. I was 
impressed with what a clear overview of 
many aspects of individualized develop-
mental care and NIDCAP that is present-
ed. The personalities, the essence of who 
and what we are really comes through. 
As usual, I am very proud to share it with 
potential funders and colleagues. Thank 
you all for all of your hard work--it is 
quite amazing.

And gretchen and Rodd, congrat- 
ulations on your recent publication in  
The Journal of Perinatal and Neonatal 
Nursing on NIDCAP. This is an excellent 
piece for nurses and NICU staff as well as 
managers and organizers. I have sent it all 
around the University of California at San 
Francisco. Its publication is very helpful 
for the work we are trying to generate 
here. Thank you for helping us elucidate 
and articulate the core of what we do.  

Sincerely,
Kathleen VandenBerg, PhD

Dear Editors,
Presently as a NIDCAP Trainee as well 
as the physical therapist dedicated to 
the NICu and also the chairperson of 
the NICu Development Council, I am 
embarking on the NIDCAP Advanced 
Practicum towards certification. Having 
completed ten systematic NIDCAP obser-
vations of premature infants during a care 
or procedure has prepared me to progress 
to the next phase. In light of beginning 
the process of the advanced practicum 
(AP), I felt compelled to share my reflec-
tions of the process thus far.

For me the road to become NIDCAP 
certified began one year ago. gretchen 
Lawhon came to St. Luke’s Hospital in 
Bethlehem/Allentown, Pennsylvania to 
provide the initial knowledge, guidance, 
and instruction on how to perform the 
NIDCAP observations of premature 
infants. Filled with excited anticipation I 
began to observe changes in infants that 
I had never observed. From this initial 
experience, I learned to develop a bet-
ter understanding of premature infants’ 
methods of communication noticing 
physiologic and behavioral changes of 
infants before, during and after their care. 
From this point on my role became that 
of the translator of the infants’ needs and 
dislikes for their caregivers.

Taking the time to exclusively observe 
an infant without performing an inter-
vention is a valuable opportunity to fully 
embrace the infant’s stressors and likes. 
Heightening my attentiveness to infants’ 
reactions taught me to stop what I am do-
ing when I see small signs of stress. This 
gives the infant a chance to recover and 
manage his/her care to minimize stressful 
procedures. Despite over thirty years of 
working with infants of various ages in 
center-based programs and in the infants’ 
homes, I found that there is a tremendous 
amount to learn and to marvel at when 
discussing infant growth and developmen-
tal achievements.

I look forward to developing a special 
relationship with the infant and family 
during my AP experience by meeting 
with them weekly or biweekly. With this 
practicum I look forward to being able to 
share my findings with the parents and 
caregivers. During that time I will have a 
chance to integrate what I have learned 
and be creative with the communication 
baby booklet.

Despite working with infants for 
many years in their homes with Early  

Intervention, this will be my first experi-
ence going from up to 72 hours post birth 
to the home visit. I look forward to imple-
menting individualized care and hopefully 
alluring the staff to embrace this concept. 
Providing suggestions for the family and 
staff will be challenging but extremely 
motivating. Throughout this practicum 
there will be opportunities arising to 
monitor changes and improvements. 
Additionally I have the distinct pleasure 
of evaluating my soon to be “practicum 
infant” in the Developmental Follow  
Up Clinic after discharge. This will 
provide an opportunity for a longitudi-
nal observation. The ultimate goal is to 
strengthen the relationship of the infant 
with his/her parents.

The AP will help me to enhance my 
observations and be able to impart my 
findings to minimize stressful situations 
with the infant and develop a family 
centered atmosphere. The infant’s devel-
opment and neurologic organization can 
be enhanced through ongoing nurturing 
care. I feel that the following Kahil Gi-
bran quote speaks very well of what we try 
to strive for with the NIDCAP practicum: 
“Progress lies not in enhancing what is, 
but in advancing toward what will be.”

Sincerely,
Maureen Rinehimer, PT, MS, MHS  
(E I Certified)

Dear Editors,
The Developmental Observer is a tri-

umph. I enjoyed the spring edition very 
much -interesting, informative and highly 
readable. I hope all my trainees are signed 
up for it, if not they are missing out. I 
know how much work (well probably 
I don’t!) this must have taken and you 
should be very proud of the result. 

Inga Warren, Dip COT, MSc

l e T T e r s  T O  T h e  e D I T O r s



18  •  �008  •  Developmental Observer

C u r r e N T  D e V e l O P M e N TA l  r e s e A r C h  Continued from page 14

Center for Excellence in Developmental and Related Disabilities. 
She is on the faculty for medical, nursing, therapy and other 
professional students with a goal of teaching family centered 
perspectives, particularly for children with disabilities and their 
families. Tracy is also a course facilitator for Ethics in Health 
Professions and is the Family Centered Care Consultant at the 
Children’s Hospital in Denver. As a professional advocate, she 
is a master of facilitating dialogue between families and hospital 
systems to improve collaboration and resolve differences. Each of 
these important positions provides opportunities for influencing 
systems and culture change. Her leadership has been instrumental 
in a shift of the entire hospital’s environment, policies and proce-
dures toward family centered care.  

Tracy’s trademark is her bright smile regardless of personal 
or professional adversity. Recently she was hiking in the Colo-
rado mountains and suffered a painful snakebite, which caused 
her to become quite ill. However, she quickly returned to work, 
which is her passion, with her ever-present smile and positive 
attitude. Tracy’s experiences with her daughter Hayley have 
shaped the person she is today. Although Hayley had a number 
of challenging outcomes from her difficult start in life, Tracy 

always focused on Hayley’s triumphs and individual capabilities 
rather than her disabilities. Tracy learned the best of life from 
Hayley and she applies those lessons to her work with individuals 
with disabilities and their families. Due to her unique personal 
experiences Tracy realizes that she has a special “insider” perspec-
tive and looks forward to sharing her vast knowledge base with 
the NFI Board. She feels the NFI will provide a broader range of 
opportunities to help others understand the strengths and chal-
lenges of having a baby in an NICU.  

Both Vicky and Tracy have crossed paths in their professional 
and sometimes personal lives with Dr. Joy Browne, whose respect 
for each of them cannot be measured. If you want heart, soul, and 
a deep knowledge in support of babies and their families, Vicky 
and Tracy are the people you want on your side. The NFI Board is 
fortunate to have such dynamic and invested individuals join the 
effort in encouraging the implementation of developmental and 
family centered care. Their contributions and consultation will 
assure the ongoing quality of the Newborn Individualized Devel-
opmental Care and Assessment Program (NIDCAP) approach in 
all intensive and special care nurseries around the world. 

References:
1. Kramer MS, Aboud F, Mironova E, Vanillovich I, Platt RW, Matush L, Igumnov S, 

Fombonne E, Bogdanovich N, Ducruet T, Collet JP, Chalmers B, Hodnett E, Davidovsky 
S, Skugarevsky,O, Trofimovich O, Kozlova L, Shapiro S. Breastfeeding and child   cognitive 
development:new evidence from a large randomized trial. Archives of General Psychaitry. 
2008; 65 (5): 578-84.

2. Baby Friendly Initiative, http://www.babyfriendly.org accessed June 2008.
3. Wechsler Abbreviated Scales of Intelligence (WASI), 1999, Harcourt Assessment Inc  

http://www.harcourtassessment.com accessed June 2008.
4. Vohr BR, Poindexter BB, Dusick AM, McKinley LT, Wright LL, Langer JC, Poole WK. 

Beneficial effects of breast milk in the neonatal intensive care unit on the developmental 
outcome of extremely low birth weight infants at 18 months of age. Pediatrics. 2006; 118 
(1): e115-123.

5. Bayley N, 2001, Bayley Scales of Infant Development-II, The Psychological Corporation, 
http://www.harcourtassessment.com accessed June 2008.

6. Feldman  R, Eidelman AI. Direct and indirect effects of breast milk on the neurobehavioral 
and cognitive development of premature infants. Developmental  Psychobiology. 2003; 43 
(2): 109-119.

7. Lucas A, Cole TJ. Breast milk and neonatal necrotizing enterocolitis. Lancet. 1990; 336: 
1519-1523.

8. Pregnancy Risk Assessment Monitoring System (PRAMS): Methodology. Available at 
http://www. cdc.gov/prams/methodology.htm accessed January 2008.

9. Colaizy TT, Morriss FH. Positive effect of NICU admission on breastfeeding of preterm US 
infants in 2000 to 2003. Journal of Perinatology. 2008; March: 1-6.

10. Warren I, Tan GC, Dixon P, Ghaus K. Breast feeding success and early discharge for preterm 
infants: the result of a dedicated breast feeding programme. Journal of Neonatal Nursing. 
2000 6 (2): 43-48.

11. Profit J, Zupancic JA, McCormick MC, Richardson DK, Escobar GJ, Tucker J, Tarnow-
Mordi W, Parry G. Moderately premature infants at Kaiser Permanenta medical care 
Program in California are discharged home earlier than their peers in Massachusetts and 
the United Kingdom. Archives of Disease in Childhood, Fetal Neonatal Edition. 2006; 91: 
F245-F250.

12. Nyqvist KH. Early attainment of breastfeeding competence in very preterm infants Acta 
Paediatrica. 2008; 97: 776-781.

13. Sisk PM, Lovelady CA, Dillard RG, Gruber KJ. Lactation counseling for mothers of very 
low birthweight infants: Effect on maternal anxiety and infant intake of human milk. 
Pediatrics. 2006; 117 (1): e67-e75.

14. Kavanaugh K, Meier P, Zimmermann B, Mead L. The rewards outweigh the efforts: breast-
feeding outcomes for mothers of preterm infants. Journal of Human Lactation. 2008; 31 
(1): 15-21.

s u P P O r T I N G  FA M I l I e s  Continued from page 13

assumptions of caregivers, just as a thoughtful understanding of 
the synactive theory and its implications is far more important 
than any single positioning aid or nursery furnishing. NIDCAP 
professionals will find any of the references listed immediately to 
the right, but especially the introductory chapters in Cassidy and 
Shaver’s (2008) second edition, are wonderful guides to the vast 
world of attachment literature. As caregivers grasp and integrate 
these principles, they will be even more equipped to support 
relationship and brain development in the most fragile infants 
and their families.

References:
1. Als H.Toward a synactive theory of development: promise for the assessment and support of 

infant individuality. Infant Mental Health Journal. 1982; 3, 229-243. 
2. Cassidy J, Shaver PR. Handbook of Attachment, Second Edition. New York: Guilford Press; 

2008.
3. Bowlby J. Attachment, Second Edition.  New York: Basic Books; 1982. 
4. Karen R. Becoming Attached: First Relationships and How They Shape Our Capacity to 

Love. New York: Oxford University Press;1998.
5. Lieberman A.F, Van Horn P. Psychotherapy with Infants and Young Children: Repairing the 

Effects of Stress and Trauma on Early Attachment. New York: Guilford Press; 2008.
6. Als H, Lawhon g, Duffy FH, McAnulty GB, Gibes-Grossman R, Blickman JG. Individual-

ized developmental care for the very low-birth-weight preterm infant: Medical and neuro-
functional effects. Journal of the American Medical Association. 1994; 272, 853-858.

7. Als H, Duffy FH, McAnulty GB, Rivkin MJ, Vejapeyam S, Mulkern RV, Warfield SK, 
Huppi PS, Butler SC, Conneman N, Fischer C, Eichenwald EC. Early experience alters 
brain function and structure. Pediatrics. 2004; 113, 846-857.

8. Cozolino K. The Neuroscience of Human Relationships: Attachment and the Developin 
Social Brain. New York: Norton; 2006.

N I D C A P  P r O F I l e  Continued from page 12



Developmental Observer  •  �008  •  1�  

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Table of ContentsFamily Voices............................................. 1

Message from the NFI President ........... 3

NIDCAP Training Centers from Around 

the World ................................................ 7

The Neuroscience of Skin-to-Skin 

Contact.................................................... 8

NIDCAP Reflections................................ 10

NIDCAP Profile ........................................ 12

Supporting Families ................................ 13

Current Developmental Research........ 14

Developmental Resources .................... 15

Letters to the Editors .............................. 17

Donnisha McCadden has had three pregnancies. The first two led to the birth of 

three extremely early born infants, who were too young to survive. Then one year 

after the second pregnancy, Donnisha and her partner, Gary Boyd, were expect-

ing another set of twins. Their story was gathered from telephone interviews.

The Pregnancy and the Birth

DONNISHA: I found out I was pregnant very early on. I was maybe around four to 

six weeks pregnant. I got the cervical circlage around three months. My doctor took me 

out of work. As the babies started to gain weight, lying around all day became strenu-

ous. However, I did it. 
GARY: Donnisha was pregnant with twins and we had a test in the hospital where they 

stuck a needle down in her belly and took some amniotic fluid. Gabby was supposed to 

be the one that had the worst possibility of making it. They were talking about a whole 

host of things that could have been wrong with her. The baby that was positioned 

lower in the uterus, her brother Gavin, was fine. No issues whatsoever. So we were 

most concerned about Gabby. Tenfold.

DONNISHA: When the babies actually started to get heavy is when the premature 

labor started for me. I went into labor on December 27 th, two days after Christmas 

and the doctors and nurses 

did everything they could 

to stop it and it actually 
stopped. Maybe a day or 

two later, I got transferred 

to Cooper University 
Hospital (in Camden, New 

Jersey) and the doctors gave 

me magnesium (sulfate) to 

stop my labor and it finally 

worked. So I stayed in the 

hospital actually for a week 

and that was a good thing. 

I think that, that week, I 
was happy because I was 

like okay “I can do this, I 

can do this, I can do this.” 

Then the circlage started to 

2008
Vol. 2   No. 2 

NIDCAP Federation 
International (NFI)

Founded in 2001, the NFI is an in-

ternational, non-profit membership 

organization. The NFI encourages the 

implementation of developmental care 

and assures the quality of the Newborn 

Individualized Developmental Care and 

Assessment Program (NIDCAP) ap-

proach in all intensive and special care 

nurseries around the world. The NFI 

serves as the authoritative leader for 

research, development, and dissemina-

tion of NIDCAP, and for the certification 

of trainers, health care professionals, and 

nurseries in the NIDCAP approach.

DevelopmentalObserver
The Official Newsletter of the NIDCAP® Federation International

Family VoicesDonnisha McCadden & Gary Boyd 

“Courage is what it takes to stand up 

and speak; courage is also what it 

takes to sit down and listen.”Winston Churchill

Continued on page 2

Developmental Care in the Moment

photograph by Karin Schrage-Hoon

Comforted.

Developmental 
  Observer

NIDCAP Federation International Board Officers, Members and Staff

The Official Newsletter of the NIDCAP® Federation International

President
Heidelise Als, PhD
NIDCAP Senior Master Trainer
APIB Master Trainer
Director, National NIDCAP  
Training Center
email: heidelise.als@childrens.
harvard.edu

Vice President 
gretchen Lawhon, RN, PhD
NIDCAP Master Trainer
Director, Mid-Atlantic NIDCAP 
Center
email: Lawhon-gretchen@ 

cooperhealth.edu

Secretary
Deborah Buehler, PhD
NIDCAP Master Trainer
APIB Trainer
West Coast NIDCAP and APIB 
Training Center
email: deborahbuehler@comcast.net

Treasurer
Gloria McAnulty, PhD
National NIDCAP Training Center 
email: gloria.mcanulty@childrens.
harvard.edu

Assistant Secretary
Sandra Kosta, BA
National NIDCAP Training Center 
email: sandra.kosta@childrens.
harvard.edu 

James M. Helm, PhD
NIDCAP Senior Trainer
Director, Carolina NIDCAP  
Training Center
email: jimhelm@med.unc.edu

Tracy Price-Johnson, MA 
Faculty at UCDHSC and 
The Family Centered Care  
Consultant at The Children’s  
Hospital in Colorado  
email: Price-Johnson.Tracy@ 

tchden.org

Roger Sheldon, MD
Co-Director, Sooner NIDCAP  
Training Center
email: roger-sheldon@ouhsc.edu

Jacques Sizun, MD
Director, French NIDCAP Center
email: Jacques.sizun@chu-brest.fr

Karen Smith, RNC, MEd
NIDCAP Senior Trainer
St. Luke’s Regional Medical Center
email: smithka@slrmc.org

Kathleen VandenBerg, PhD
NIDCAP Master Trainer
Director, West Coast NIDCAP and 
APIB Training Center
email: kavandenberg@yahoo.com

Victoria Youcha, EdD 
Child Development Specialist 
Children’s Medical Associates 
Alexandria, VA 
email: vyoucha@gmail.com

David Wahl
Director of Development and  
Administration
email: nfidirector@nidcap.org



NIDCAP Federation 
International (NFI)
www.nidcap.org

by order of establishment

N I D C A P  T r A I N I N G  C e N T e r s

Become a Member  
of the NFI
The NFI has expanded opportunities 
for membership to Certified NIDCAP 
Professionals, NIDCAP Trainees, and 
Families of Premature Infants.  
Please join us! For more information  
and the online application form,  
visit our website at:  
www.nidcap.org.

National NIDCAP Training Center
Brigham and Women’s Hospital and
Children’s Hospital Boston
Boston, Massachusetts USA
Contact: Sandra M. Kosta, BA
email: sandra.kosta@childrens.harvard.edu

Sooner NIDCAP Training Center
University of Oklahoma Health Sciences
Center, Oklahoma City, Oklahoma USA
Co-Director and Contact:  
Laurie Mouradian, ScD, OTR/L
email: laurie-mouradian@ouhsc.edu

Carolina NIDCAP Training Center
WakeMed
Raleigh, North Carolina USA
Director and Contact:  
James M. Helm, PhD
email: jimhelm@med.unc.edu or
jhelm@wakemed.org 

Colorado NIDCAP Center
University of Colorado, Department of
Pediatrics at The Children’s Hospital
Denver, Colorado USA
Director and Contact:  
Joy V. Browne, PhD, CNS
email: browne.joy@tchden.org

West Coast NIDCAP and APIB 
Training Center
San Francisco, California USA
Director and Contact:  
Kathleen VandenBerg, PhD
email: vandenbergk@peds.ucsf.edu

St. Luke’s NIDCAP Center
St. Luke’s Regional Medical Center
Boise, Idaho USA
Contact: Karen M. Smith, RNC, BSN, MEd
email: smithka@slrmc.org

Mid-Atlantic NIDCAP Center
The Children’s Regional Hospital at
Cooper University Hospital
Camden, New Jersey USA
Director and Contact:  
gretchen Lawhon, RN, PhD
email: lawhon-gretchen@cooperhealth.edu

Scandinavian NIDCAP Center,
Lund and Stockholm, Sweden
Astrid Lindgren Children’s Hospital, Stockholm;
Children’s Hospital, Lund University Hospital,
Lund and Department of Pediatrics, Borås 
Hospital
Contact: Ann-Sofie Gustafsson, RN, BSN
email: nidcap@karolinska.se

French NIDCAP Center, Brest, France
Medical School, Université de Bretagne
Occidentale and University Hospital
Brest, France
Co-Director and Contact:  
Nathalie Ratynski, MD
email: nathalie.ratynski@chu-brest.fr

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

Centro Latinoamericano NIDCAP
Fundación Dr. Miguel Margulies
Buenos Aires, Argentina
Director and Contact:  
Maria Costanza Margulies
email: conicerullo@gmail.com or
basso.grace@gmail.com

UK NIDCAP Training Centre at St. Mary’s
St. Mary’s NHS Trust 
London, England
Director and Contact:
Inga Warren, Dip, COT, MSc
email: inga.warren@imperial.nhs.uk

University of Illinois Medical Center at 
Chicago (UIMCC) NIDCAP Training Center
Women’s and Children’s Nursing Services
University of Illinois Medical Center  
at Chicago
Chicago, Illinois USA
Contact: Jean Powlesland, RN, MS
email: jpowlesl@uic.edu

The NIDCAP Training Center at 
Connecticut Children’s Medical Center
Connecticut Children’s Medical Center
Hartford, Connecticut USA
Co-Director and Contact:  
Dorothy Vittner, RN, MSN
email: dvittner@ccmckids.org

NIDCAP Training and Research Center
at Cincinnati Children’s
Cincinnati Children’s Hospital
Medical Center
Cincinnati, Ohio USA
Contact: Tammy Casper, MSN, RN
email: tammy.casper@cchmc.org

The Brussels NIDCAP Training Center, 
Belgium
Department of Neonatology
Saint-Pierre University Hospital
Free University of Brussels
Brussels, Belgium
Contact: Delphine Druart, RN
email: ddruart@hotmail.com