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Evaluation of Neonate in NICU: A neonatal therapist perspective

September 7, 2021

Evaluation of infant development in the NICU is a complex process involving integration of information from a variety of sources and interaction with a number of team members. 

Essential components of neonatal evaluation 

The purpose of a neonatal therapy evaluation is to assess an infant's capacities and his or her participation in the essential developmental tasks and occupation of infancy. 

The major elements of a neonatal therapy evaluation are 

  • Medical consideration and stability 
  • Physiological homeostasis 
  • Neurobehavioral organization 
  • Motor organization 
  • Active engagement with the environment

These elements can be assessed using standardized assessment tools, observation, handling or combination of these methods. 


Medical consideration and stability 

Medical stability is the utmost prerequisite for neonatal therapy to begin. The most important aspect is stable vital signs. But other medical considerations we shall check before administration of any stimulation is current medication and recent procedures. Is there any medication which an infant is currently receiving or weaned off which can make an infant lethargic. Secondly, check for some procedures or situations that account for physiological instability or fatigue like a recent heel stick, IV may have fatigued an infant, you shall consider a pain management rather than a stimulation session.

Must Read - Inside the NICU: What Are the Different Levels of Neonatal Care?


Physiological homeostasis 

The initial observation should always include observing and analyzing the physiological stability of an infant. Like, look for any changes in skin color, changes in heart rate, respiratory rate, oxygen saturation, and body temperature. If you find all stable signs, we can proceed further. During the handling we may find some instability so it’s important to pause and wait for the recovery and if taking too long or repeating frequently, we shall report to the attending nurse or neonatologist. To recognize when to stop/pause during an assessment or the stimulation session, it is significant to know these signs of instability. 


Neurobehavioral organization 

The two most important aspects of Neuro behavioral organization are state of arousal or ability to self-regulate. 

State of arousal: An assessment of infant state of arousal provides a baseline for all other behavioral observations. We all know there are 6 states for arousal starting for deep sleep, light sleep, drowsy, quiet alert, active alert and last is crying. As a neonatal therapist what is important to assess and observe is 

  • Quality of each state, especially quiet alertness 
  • Smoothness with which the infant moves from one state to the other. 
  • Degree of irritability experienced by the infant 
  • Ability to self soothe 

Infants who have difficulty organizing or regulating their state of arousal may experience difficulty interacting with their environment and participating in age appropriate activities. 

Ability to self-regulate: self-regulation includes the infant’s ability to 

  • Habituate to repeated stimuli and to protect his or her sleep 
  • Tolerate basic care as well as painful or stressful stimuli 
  • Respond to caregivers social interactions at a minimum physiological cost
  • Make active efforts to self-regulate state of arousal 

Must Read - Which newborn babies need Neonatal Care?


Motor organization 

Assessment of postural and motor capacities is another essential component of neonatal evaluation. For self-regulatory behavior an infant's capacity to interact with their environment often rely on motor organization. Key components of Neuromotor assessment include: -

1. Undisturbed posture at rest, including position and symmetry of the limbs.

2. Response to handling and repositioning.

3. Age appropriate motor responses- reflex assessment, proprioceptive response, visual response and auditory response.


Active engagement with the environment

Physical environment: assessing the physical environment’s possible influence on the infant's neurobehavioral organization is a very important aspect of neonatal intervention. The attributes of environmental stimuli to which the infant is exposed should be noted throughout the entire observation period. The other important stimuli attributes to consider are:

  • Type of sensation being experienced or sensory system being stimulated
  • Strength of the stimulus  required to reach the response threshold 
  • Length of exposure to the stimulus required to elicit a response. 

Social environment: Assessment of infant social environment must include various elements of the infant social interactions related to infant, family or other caregiver. Infant factors to be considered are the ability to tolerate social approaches without physiological stability. Analyzing an infant alert time. Family factors to be considered: how often the mother visits, her availability for KMC and learning developments interventions at home. 


A contextual approach that incorporates direct observation with information from a variety of sources allows the therapist to obtain the most comprehensive view of infant’s ability and availability to participate in developmental appropriate intervention

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