Preemie Signals

Early communication and parent education

According to the March of Dimes, approximately 12.5 percent of babies-over half a million infants annually-are born prematurely, a rate that has increased 30 percent since 1981.1

Recent research has found that later preterm infants have a higher risk of developmental delays than full-term babies.2

Clinicians who work frequently or exclusively with babies born prematurely must be knowledgeable about the medical diagnoses most likely to carry risks of later delays and have the ability to recognize and explain to parents the unique communicative needs of these infants.

"There are no crystal balls, but the more medically complex a baby is with diagnoses associated with poor developmental outcomes, the more rigorous you need to be with your developmental surveillance," said Brenda Hussey-Gardner, PhD, MPH, assistant professor of pediatrics and coordinator of the NICU Follow-Up Program at the University of Maryland School of Medicine in Baltimore.

A study at the university examined infants' diagnoses upon discharge from the NICU and the correlation to the later receipt of early intervention services. "We found that diagnosis of chronic lung disease, grade III or IV intraventricular hemorrhage, and surgical necrotizing enterocolitis correlated with later receipt of speech services," she told ADVANCE. "When we looked at our research population when they turned 3, speech was the most frequently received service under Part B. Forty percent of our children qualified for speech services."

But long before early intervention services commence, clinicians often are consulted for parent education. Ensuring that parents are educated fully about their child's diagnoses and unique communicative needs is necessary for the success of any treatment and follow-up plan for infants leaving the NICU. Initial parent concerns often focus on feeding and motor issues, as well as the same anxieties expressed by parents of full-term infants.

Clinicians need to be prepared to discuss these issues, Dr. Hussey-Gardner said. "You might think it's outside of your scope, but sometimes the things that are the hot topics for mom and dad need to be addressed before or parallel with what we're working on therapeutically. If you can help a family get their child to sleep through the night, mom and dad will sleep through the night, and they're going to have the energy to work on more of the therapy goals."

One of the earliest education points that she explains to parents is the unique communicative methods of preemies and how to use those cues to foster development. She tells parents about an infant code referred to as "preemie signals" based on the research of Heidelise Als, PhD, director of Neurobehavioral Infant & Child Studies at Children's Hospital Boston and originator of the Newborn Individualized Developmental Care and Assessment Program, an individualized, behaviorally-based developmental care model.3

"Babies have behavioral and physiological signals that let us know when they are ready for stimulation, when they are helping themselves cope, and when they are over-stimulated and need help," Dr. Hussey-Gardner explained.

The signals are divided into three categories: approach, coping and avoidance. Preemies use these signals as a means of communicating with their family. Approach signals, which indicate relaxation, include cooing, smiling and mouthing. Coping signals are actions that seek stability, such as sucking on a pacifier, holding onto something, or bracing a leg against an object. Since many preemies do not have a vocal cry, agitation can be expressed through the avoidance signals of finger splays, salutes, tongue thrusts or grimaces.

"Approach signals say the baby is happy and ready for interaction or feeding. Coping signals show the baby is helping himself cope with environmental stimuli, and avoidance signals say the baby needs a change; he needs some help," Dr. Hussey-Gardner said. She developed a pamphlet titled Understanding My Signals to explain preemie signals to parents and offer strategies for interacting with a preterm infant, which often differs from interacting with full-term infants.4

If a baby cries, the typical response is to hold the baby. If the baby still cries, you pat and jostle him and might sing to him," she noted. While this approach works for full-term babies, it tends to over-stimulate preemies, whose crying often is preceded by finger splays, salutes and grimacing. Parents are unaware of these signals and don't notice them or don't know how to respond to them appropriately. "Parents tend to feel that they're not successful in interacting with their babies because they respond with too much stimulation when the baby needs a little less instead of a little more," she said.

A thorough explanation of the signals helps to eliminate some new parent anxieties. A common scenario involves a mother who tries to console the baby through different ways, becomes frustrated when they don't work, gives up, and puts the baby down on a blanket. "The baby calms down, and the mom thinks, 'My baby doesn't love me.' What the baby really needed was just to be held quietly with one stimulation at a time, which may have just been touch. Once the baby can handle that, mom can add her voice, watching for the signals that tell her when the baby is ready for more."

Parents should talk to their baby first to prepare the baby for being touched, she advised. They should allow their baby a brief respite between such activities as feeding, playing or a diaper change, she advised. "A little break might just be a few seconds of quietly holding the baby, watching for when the baby starts to show readiness signals, and then beginning with one stimulation at a time. It's so easy to talk and rock and pat all at the same time, but that can be too much."

Parents who pay close attention to their infant's signals often retain the habit well into the child's maturity, Dr. Hussey-Gardner noted. "If you talk to parents of babies born prematurely, they're really in tune with their children as they get older and can help read their signals and respond to their nonverbal bids for communication."

Baby massage also can help foster early communication. "I'm a big believer in touch as an early form of communication," she said. "Any baby who's been in the NICU has had some not-so-nice touches, and it's nice to know that the world has nice touches, especially when it comes from mommy, daddy or grandma."

Even parents who are not especially verbal with their infants can use a simple narration, such as "Mommy's going to rub your arm," during the massage and use the experience to closely observe the baby's signals. "It lays a nice foundation for reciprocal interaction and for using a lot of rich language and verbally describing things, which will be beneficial to language development down the line," she said.

After infants leave the NICU at the University of Maryland, they generally participate in a multidisciplinary follow-up program to determine eligibility for early intervention services and to receive treatment from different disciplines based on their medical needs and developmental milestone progress. The NICU Follow-Up Program follows infants from a number of NICUs across the state, which requires long commutes for many families. Therefore, clinicians in the program encourage families to become involved in their local early intervention program.

The state early intervention program in Maryland includes a home care component for service provision. Home care programs could place early intervention speech-language pathologists in Maryland and other states with similar programs in an important position to monitor overall development beyond an NICU follow-up program.

"If a speech therapist is the key professional in a child's individualized family services plan [IFSP], visiting the child and family once a week or once a month, she can spot-check how development is doing in the other domains. She may be the best person to catch something early," Dr. Hussey-Gardner said. "Even if the child attends a NICU follow-up program routinely, program staff may only see the child every three to six months. The therapist may be in the house much more frequently than that."

Early intervention eligibility varies widely by state. Indicators for eligibility include birth weight, gestational age and medical diagnoses. Some states provide automatic eligibility for children born with a high-probability medical condition. For instance, infants automatically qualify for services in New Mexico if they are born at less than 35 weeks and in Wisconsin if they are born at less than 27 weeks.5

Speech-language pathologists should be aware of whether age adjustment is a factor in service provision and explain these policies to parents, Dr. Hussey-Gardner said. "It's important to understand where your agency and state fall with regards to adjusting age for prematurity. Some programs may not adjust at all and will look at the child at a chronological level, while others embrace adjusting to look at a child's development through their adjusted versus chronological age to maybe one or two years."

No matter what kind of program a child enters, speech-language pathologists should make their knowledge and expertise available to parents and colleagues, even in non-language-specific areas such as positioning, she advised. "Even when it comes to positioning, there is a role for speech and language. Tummy time is so important for gross motor development, and it's important for speech-language pathologists to share with physical therapists that babies are going to tolerate tummy time better if they're being engaged by an adult in face-to-face verbal interaction."

A simple combined language and motor development exercise is for the baby to lie on the parent's chest. As the parent speaks, children inevitably will pick up their head, thus strengthening their muscles. "So often everyone is concentrating on whether the diaper roll is under the hips the right way. A physical therapist will take care of that. Social and communication engagement are what will make babies more successful during tummy time. It will ultimately help motor outcomes."


1.Hamilton, B.E.; Ventura, S.J., Martin, J.A., et al. (2006). Births: Final data for 2004. National Vital Statistics Reports, 55 (1).

2.Petrini, J.R., Dias, T., McCormick, M.C., et al. (2009). Increased risk of adverse neurological development for late preterm infants. Journal of Pediatrics, 154 (2): 159-60.

3.Als, H., Gibes, R. (1990). Newborn Individualized Developmental Care and Assessment Program (NIDCAP). Training Guide. Boston: Children's Hospital.

4.Hussey-Gardner, B. (2008). Understanding My Signals: Help for Parents of Premature Infants (3rd ed.). Palo Alto, CA: VORT.

5.Hussey-Gardner, B., Famuyide, M. (2009). Developmental interventions in the NICU: What are the developmental benefits? Neo-Reviews, 10 (3): e113-20.

For More Information

•Brenda Hussey-Gardner, PhD,

Alyssa Banotai is a Senior Associate Editor at ADVANCE. She can be reached at

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