Understanding Your NICU Baby’s Behavior

By Susan Horner, PhD, APRN-CNS, RNC-NIC; Developmental Specialist, NICU

Adults use verbal and non-verbal behavior or body language in communicating with others. Although young infants cannot communicate using words, they do convey their needs and wants through behaviors called infant cues. Infants in the NICU also use cues to communicate with their families and NICU caregivers.

Infants use both potent (easy to see) and subtle (more difficult to see) behaviors or cues. Whether your NICU baby is premature or a full-term baby in need of NICU care, their cues are more likely to be subtle. This is because sick and preterm infants may lack the energy needed to use more potent cues such as vigorous crying.  

Infant cues typically fall into two categories. Some cues communicate that babies are comfortable or ready to interact with their caregivers by looking at or listening to them. Other cues indicate that the infant is uncomfortable or stressed and in need of a break or a change to return to a relaxed state. In the NICU, cues indicating that the infant is uncomfortable or stressed are often referred to as stress cues.

NICU Infant Cues

The subtle cues used by NICU infants to communicate comfort or stress include levels of alertness, facial expressions, movements, and changes in vital signs. Cues used frequently by NICU infants are listed below. Please keep in mind that because infants are individuals, every NICU infant will have a unique set of cues that are typical for them. Learning about your baby includes learning about their typical cues and responses to caregiving and the environment.

Cues indicating your NICU baby is comfortable and may be ready for gentle interactions: 

• Stable vital signs
• Pink color
• Relaxed, flexed posture
• Smooth movements
• Quiet alert state
• Looking toward caregiver

Cues indicating your NICU baby is stressed and is in need of a break or a change:

• Changes in vital signs: Fast or slow breathing or heart rate; falling oxygen saturation
• Pale, flushed, mottled or blue color
• Yawning or sighing
• Hiccoughs or sneezing
• Gagging or vomiting
• Grimacing or frowning
• Low trunk or facial tone
• Finger splaying (finger or fingers extended out with tension)
• Saluting (stop sign with fingers extended; arm may be extended)
• Extending arms and/or legs out with tension
• Flailing movements
• Staring or hyper-alert facial expression
• Looking away
• Dull looking face & eyes
• Shutting down (state lowering to sleep state)

Cues indicating your NICU baby is attempting to help themselves:

• Bracing or pushing feet against something (i.e. bedding roll)
• Bringing hands to mouth
• Bringing hands or feet together
• Grasping
• Sucking

Responding to Your NICU Infant’s Cues

Being in the NICU can be a stressful time for parents. Not knowing how to help your baby feel safe and comfortable may add to feelings of helplessness. By observing your NICU baby’s cues and ways they try to help themselves, you can learn their typical cues and learn to help them stay more comfortable and relaxed. For example, if you notice your baby responds to diaper changes with signs of stress, you can offer your finger for the baby to grasp or a pacifier for the baby to suck. As you learn your baby’s typical cues and self-help activities, be sure to share these with NICU staff.     

Lurie Children's NICU is a Level III facility, which is the highest designation in Illinois for the level of specialized expertise and comprehensive resources available to treat the smallest and sickest babies. Patients in our 64-bed unit have immediate onsite access to 70 pediatric medical and surgical subspecialists, which allows us to treat a patient’s every need, no matter how complex. Learn more about our Neonatology team.