Background Neurodevelopmental outcomes are of paramount importance for every clinician as the survival rates of term and preterm babies have continued to improve. In NICU every intervention should be aimed at either promoting the neurodevelopment or prevent any further insult to a premature brain. We aim to provide a framework for developing a Neuroprotective strategy for the Neonatal Intensive Care Unit (NICU) by describing five main domains below.

Objectives We achieve this in our NICU by a multi-disciplinary team consisting of neonatologists, respiratory therapists, occupational therapists, physiotherapists, social workers, pharmacists, and a dietician. This approach needs to be individualised for each unit based on the resources and services available.

Conclusions Neuro assessment: clinical neuro assessment remains the most important tool, with strong predictive value for long-term outcomes. It is important to develop other tools of assessment like comfort and pain scoring. We use comfort Neo-scale as standard care. Neuroimaging is another important factor in the assessment. We have an agreed guideline to decide the frequency and the timing of the neuroimaging like cranial ultrasound and MRI.

Neuroprotection: Antenatal magnesium sulfate and antenatal steroids have become an established practice in most units^1,2. Interventions like total body cooling have significantly improved the outcomes for babies with Hypoxic-ischemic injury. Optimal nutrition is another important element for the developing brain. We developed neonatal nutritional guidelines in collaboration with the clinical pharmacist and a dietician. Introduction of starter parenteral nutrition bags for out of hours use and having evidence-based feeding guidelines are known to improve the outcomes. We practice the golden hour protocol for all babies born before 28 weeks gestation and have introduced intra ventricular haemorrhage (IVH) prevention bundles³ for the same cohort of babies. Even though individual components of these bundles do not have strong evidence, there is some benefit when these interventions are offered as a bundle. Our care bundle involves midline positioning, using log roll, minimal handling, maintaining normothermia, avoiding IV boluses, and maintaining normal CO2 levels

Neuromonitoring: Tools like an amplitude-integrated electroencephalogram (aEEG), near-infrared spectroscopy (NIRS), and onsite MRI are gaining popularity. eEEG should be routinely used in Hypoxic Ischemic Encephalopathy (HIE) babies when available. All team members should be trained in its application and interpretation. Near Infra-Red Spectroscopy is a developing modality used by few units to monitor cerebral oxygenation. We have recently started to pilot these machines.

Neurodevelopment: The environment of the NICU has been shown to affect the developing brain. Strategies should be developed to optimise the sleep of the baby by reducing lighting and noise levels. We use positioning tools like boundaries and midliners as part of their neuro development.

Neuro intervention: We use therapeutic techniques like auditory, tactile, visual, and vestibular (ATVV) stimulation⁴. It is an evidence-based technique used to increase alertness in medically stable preterm infants. We use Prechtl’s Qualitative Assessment of General Movements observational tool⁵. It is the most predictive tool (98% sensitivity) for detecting cerebral palsy. This helps provide targeted treatment at an earlier stage.