Introduction
Preterm birth, commonly defined as delivery before 37 weeks of gestation, is a significant global public health concern. Estimates from the World Health Organization (WHO) and recent epidemiological analyses indicate that about 13.4 million infants worldwide were born preterm in 2020, with reported prevalence ranging from roughly 4% to 16% across regions and populations [1, 2]. In Iran, the prevalence rate is about 11–12% [3]. Infants born prematurely are at a higher risk of neurodevelopmental problems, including developmental delays, cognitive deficits, and problems with sensory and emotional regulation. These early difficulties may persist and influence later academic performance, social participation, and overall quality of life [4, 5].
Hospitalization of infants in the neonatal intensive care units (NICUs) frequently imposes substantial psychological strain on families, particularly on mothers. Such stress can interfere with the development of secure parent-infant attachment, diminish the quality of caregiving, and potentially affect infants’ neurodevelopmental trajectories [6, 7]. As advances in neonatal medicine have improved survival among preterm infants, the focus of care has gradually shifted from survival to promoting optimal growth and developmental outcomes after discharge. The transition from the NICU to home represents a pivotal phase in the continuum of developmental care. During this stage, primary caregiving responsibilities—including managing the home environment, interpreting and responding to infant cues, and providing appropriate developmental stimulation—shift from healthcare professionals to family members [8, 9]. Because of the immaturity of their central nervous system, limited capacity for self-regulation, and heightened sensitivity to environmental stimuli, preterm infants often require continued, structured developmental support after discharge from the hospital. Moreover, parents of these infants may experience anxiety, reduced confidence, difficulties in interpreting infants’ behavioral cues, and concerns about providing care at home [6, 10]. Accordingly, post-discharge care should adopt a dyadic perspective that considers the needs of both the infant and the parents. During rapid brain development, neuroplasticity allows the nervous system to reorganize and establish new synaptic connections in response to appropriate environmental input. Therefore, intervention strategies should be informed by these neurobiological mechanisms in order to support and optimize infants’ neurobehavioral developmental trajectories [11, 12]. In response to these needs, various developmental supportive interventions have been developed; however, the existing evidence remains highly heterogeneous in terms of content, theoretical foundations, and implementation components [13, 14].
Despite previous review studies that investigated early interventions for preterm infants, these studies often have considerable methodological limitations, including insufficient attention to the theoretical frameworks underlying the interventions (such as the synactive theory) and an exclusive emphasis on reporting clinical effectiveness without presenting an integrated conceptual model. Indeed, the lack of a comprehensive evidence map to categorize the implementation characteristics and conceptual foundations of these interventions limits the standardization of post-discharge care and their adaptation to diverse healthcare systems [13, 15]. Therefore, this scoping review aimed to address these scientific and methodological gaps by systematically identifying, describing, and categorizing developmental supportive interventions for preterm infants after NICU discharge. By systematically identifying the types of interventions, their underlying theoretical frameworks, and key elements, this study seeks to develop a comprehensive and organized framework. The findings may serve as a practical, evidence-based resource for healthcare professionals, particularly occupational therapists, physical therapists, and neonatal nurses, in systematically designing and implementing developmental interventions during the critical post-discharge period.
Materials and Methods
This scoping review identifies, maps, and synthesizes available evidence while exploring knowledge gaps in a specific research area. The study followed the five-stage methodological framework developed by Arksey and O’Malley [13]. In addition, to enhance methodological rigor and reporting transparency, we followed the updated recommendations of the Joanna Briggs Institute (JBI) and the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) guidelines [14, 15]. The research questions were defined as follows: What types of developmental supportive interventions are available for preterm infants after discharge from the NICU? What theoretical frameworks underpin the design of these interventions? What outcomes have been assessed in studies?
A literature search was conducted for relevant studies from August 1 to August 15, 2024, in online databases (PubMed, Scopus, Web of Science, and Google Scholar), using a combination of keywords and related terms concerning preterm infants, early intervention, developmental care, family-centered care, parent-infant interaction, and neurodevelopmental outcomes. The PubMed search strategy was constructed as follows: “preterm infants” [Title/Abstract] OR “premature infants” [Title/Abstract] OR neonates [Title/Abstract]; “early intervention” [Title/Abstract] OR “developmental care” [Title/Abstract] OR “family-centered care” [Title/Abstract] OR “mother-infant relationship” [Title/Abstract] OR “neurodevelopmental treatment” [Title/Abstract]. For Scopus, the search strategy was modified to query the title, abstract, and keyword fields as follows: TITLE-ABS-KEY (“preterm infants” OR “premature infants” OR neonates) AND TITLE-ABS-KEY (“early intervention” OR “developmental care” OR “family-centered care” OR “mother-infant relationship” OR “neurodevelopmental treatment”). In Web of Science, the search was conducted using the topic (TS) field: TS=(“preterm infants” OR “premature infants” OR neonates) AND TS=(“early intervention” OR “developmental care” OR “family-centered care” OR “mother-infant relationship” OR “neurodevelopmental treatment”). For Google Scholar, considering the limitations in handling complex Boolean operators, the Advanced search option was used. The main keyword combinations (e.g. “preterm infants” combined with “early intervention” and “developmental care”) were searched, and the retrieved records were screened until saturation was reached in identifying relevant studies. Additionally, we manually searched the reference lists of included studies and relevant articles to maximize the comprehensiveness of the literature search.
We included studies published in English or Persian from 2000 to 2024 involving preterm infants, parents of preterm infants, or their primary caregivers. Regarding study design, only original research studies, including randomized controlled trials (RCTs), non-randomized clinical trials, quasi-experimental studies, and cohort studies, were considered eligible. Eligible studies had to focus on developmental care programs, developmental supportive interventions, family-centered care, parent education, early intervention programs, mother–infant interaction interventions, or other related interventions aimed at improving the neurodevelopment of preterm infants after NICU discharge. We also included studies in which interventions began during NICU hospitalization and continued after discharge. Additionally, included studies were required to report at least one outcome related to neurodevelopment, motor development, cognitive development, behavioral development, parent-infant interaction, or parental outcomes.
To enhance the applicability and validity of the findings, studies with very small sample sizes (<14), as well as review articles, systematic reviews, meta-analyses, case reports, case series, letters to the editor, and studies without accessible full texts were excluded. Studies involving term infants or children without a history of prematurity, as well as studies examining exclusively pharmacological, surgical, or medical interventions without a direct relationship to developmental care or neurodevelopmental support, were also excluded. Moreover, studies without a clearly defined intervention, those focusing solely on neurodevelopmental status, risk factors, prevalence of developmental disorders, or associations between variables, and those not reporting relevant developmental or infant growth outcomes were excluded.
All retrieved records were imported into EndNote reference management software, and duplicate records were removed. In the first screening stage, two reviewers independently assessed titles and abstracts against the eligibility criteria and excluded studies that did not meet them. Subsequently, the full texts of remaining studies were assessed. Studies that did not meet the inclusion criteria were excluded. Two reviewers discussed the results at each stage and resolved disagreements by consensus.
The information collected from the studies included the authors’ name, year of publication, study objective, sample size, participants, study design, theoretical foundation of interventions, intervention components and duration, instruments, and outcomes. After data extraction, a descriptive content analysis approach was applied to synthesize and categorize interventions with similar characteristics into conceptual domains. Accordingly, the identified interventions were grouped into four main categories: motor-based interventions, sensory-based interventions, behavioral interventions, and family-centered interventions focused on parental empowerment. Finally, the findings were presented and summarized in tables.
Results
The initial search yielded 3,156 records. After importing into EndNote software, 1,143 duplicate records were identified and removed. During the initial screening phase, the titles and abstracts of the remaining 2,013 records were assessed, of which 1,946 were excluded due to irrelevance to the study objectives. Next, the full texts of the remaining 67 articles were screened against the predefined inclusion and exclusion criteria. Among these, 52 articles were excluded for specific reasons, including lack of focus on preterm infants, inconsistency with developmental supportive interventions, absence of post-discharge intervention, failure to report relevant outcomes, non-interventional study designs, or insufficient information. Ultimately, 15 eligible studies were included in the scoping review.
Figure 1 presents the flowchart of the study selection process.
Table 1 summarizes the characteristics of the included studies, including objectives, participants, study designs, intervention components, assessment tools, and reported outcomes.
The analysis revealed significant heterogeneity among post-discharge developmental care programs for preterm infants based on theoretical frameworks, intervention components, duration and intensity, degree of parental involvement, and evaluated outcomes. The identified interventions were grouped into four groups of motor, sensory, behavioral, and parental empowerment (family-centered) interventions.
Table 2 presents a comparative overview of the key features of these four categories.
Motor interventions
Six studies focused on motor interventions. Three studies were based on neuro-developmental treatment (NDT) theory, which uses handling techniques and key points of control to influence movement patterns and postural stability [16–18]. The other three studies were based on action-perception theory and focused on environmental enrichment and the infant’s active participation in motor-based play and problem-solving activities [19–21].
Sensory interventions
Two studies fell into the second category, “sensory interventions”. One study used multisensory stimulation [22], while the other used the Kangaroo mother care (KMC) program [23]. The multisensory stimulation intervention simulated aspects of the intrauterine environment and included auditory, tactile, visual, and vestibular stimuli. Auditory input was delivered through soft lullabies, while tactile stimulation consisted of gentle massage with light stroking. Visual stimulation was provided using high-contrast black-and-white cards, and vestibular input was introduced through slow, controlled vertical and horizontal rocking movements [22]. The KMC emphasized skin-to-skin contact and promoting breastfeeding, helping strengthen mother–infant bonding and interaction [23]. Both interventions were initiated during NICU hospitalization and continued for up to two months after discharge.
Behavioral interventions
Four studies were into the third category, “behavioral interventions” [24–27]. These interventions were primarily based on the synactive theory of development, which considers infants’ behaviors as their primary language for expressing their states of stability or stress. This theoretical framework enables therapists and parents to support the development of self-regulatory and co-regulatory behaviors by accurately interpreting behavioral cues. In this framework, infant behaviors are understood based on cues from four interrelated subsystems (autonomic, motor, state organizational, and attentional-interactive systems) across three categories: approach, self-regulation, and stress. In each subsystem, behaviors fall along a continuum of responses ranging from no development (approach) to development (stress), with self-regulatory behaviors fall within these two responses. Infants may use self-regulatory behaviors to maintain attention and interaction, cope with more challenging interactions, or return to a stable state. Approach and self-regulatory behaviors indicate that the infant is able to tolerate environmental stimuli and benefit from environmental experiences. Conversely, the presence of stress behaviors suggests that stimulation exceeds the infant’s tolerance capacity, indicating the need for parents or therapists to modify the intensity of stimulation. Self-regulatory behaviors may also guide caregivers in applying specific co-regulation strategies, such as facilitating foot bracing or grasping attempts.
Based on these behavioral observations, intervention guidelines and strategies have been developed to reduce infants’ stress, promote their attention and interaction, and support their emerging self-regulatory abilities. These approaches further support parents in developing a clearer understanding of their infant’s behaviors, as well as their ability to process, tolerate, and respond to environmental stimuli [24–27].
Parental empowerment (family-centered) interventions
Three studies were used parent empowerment (family-centered) interventions. These interventions primarily focused on reducing parental stress associated with NICU hospitalization. By providing parents with information about infant behaviors and parental role in caregiving, and by enhancing mother–infant interaction, these programs empower parents, and improve their self-efficacy [28–30]. Analysis of the assessed outcomes in the included studies showed that motor development and function received the greatest attention (n=10) [18-21, 23, 26, 27, 29], followed by cognitive development (n=8) [18-21, 23, 26, 27, 29]. Language development and communication skills, parental stress or resilience, and behavioral outcomes and self-regulation were each evaluated in 4 studies [22, 23, 27, 29]. In contrast, social-emotional outcomes received less attention (only in 3 studies) [17, 24, 28].
Discussion
The present scoping review demonstrated that, despite considerable heterogeneity in theoretical foundations, intervention content, implementation methods, and evaluated outcomes, developmental supportive interventions for preterm infants following NICU discharge can be systematically classified into four major domains: motor interventions (n=6) [15-20], sensory interventions (n=2) [21, 22], behavioral interventions (n=4) [23-26], and family-centered parent empowerment programs (n=3) [27-29]. Although these interventions are based on different theoretical frameworks, the synthesized evidence suggests that these categories should not be considered independent or competing approaches. Rather, each addresses a specific aspect of developmental care for preterm infants and may be used as a complementary model. Sensory and motor interventions primarily aim to enhance neurodevelopmental capacities and provide appropriate developmental experiences, whereas behavioral interventions focus on supporting infants’ self-regulation behaviours and improving parent-infant interaction. In contrast, family-centered interventions facilitate the implementation of other developmental strategies at home by enhancing parental knowledge, confidence, and active participation. Therefore, the existing evidence does not support the superiority of one approach over others; they can be considered complementary elements of a comprehensive model of post-discharge, family-centered developmental care.
The results of this study align with findings from previous review studies on early intervention and neurodevelopmental care for preterm infants, but different in terms of focus. The reviews studies done by Orton et al. and Spittle et al. mainly focused on the effectiveness of early interventions and reported beneficial effects on selected motor and cognitive outcomes. However, heterogeneity in intervention types, time of initiation, program intensity, and assessment measures has limited the ability to draw definitive conclusions [9, 11]. Griffith et al. also highlighted the considerable diversity of post-discharge support programs and the lack of a unified framework for their classification [8]. Raghupathy et al. reported that family-centered interventions may improve motor and neurobehavioral outcomes in preterm infants; however, variations in program structure remain a major challenge in interpreting the available evidence [31]. The present study focused on the systematic identification and classification of interventions, their theoretical foundations, and implementation characteristics.
Regarding motor interventions, two main approaches were identified: interventions based on neurodevelopmental treatment and interventions emphasizing exploratory play, active learning, and self-initiated movement [16–21]. Traditional approaches primarily focused on facilitating typical movement patterns and postural control, whereas more contemporary approaches emphasized infant participation, interaction with the environment, and experience-based learning. One example is the supporting play exploration and early development intervention (SPEEDI) program, which was developed based on environmental enrichment principles and the promotion of active infant engagement. This shift is consistent with contemporary neurodevelopmental perspectives that highlight the important role of experience, environment, and active participation in the development of motor abilities [11, 32]. However, differences in intervention intensity and duration, the extent of parental involvement, and the outcomes assessed make direct comparisons between studies challenging. For example, while most SPEEDI studies reported improvements in motor outcomes, the study by Cameron et al., which focused on neurodevelopmental treatment, positioning strategies, and handling techniques, did not show significant differences in infant motor performance. These discrepancies may be due to differences in intervention content, opportunities provided for active learning, level of parental involvement, or the sensitivity of assessment tools used to detect developmental changes [17].
Regarding sensory interventions, identified programs mainly included multisensory stimulation and KMC-based programs [22, 23]. The common rationale underlying these interventions is the provision of structured sensory input that is appropriate to the processing capacity of preterm infants. These programs aim to transform infants’ sensory experiences from fragmented and potentially stressful events into predictable, supportive, and regulatory experiences. As reported by Pineda et al., sensory interventions vary considerably in terms of stimulus type, intensity, duration, timing, and implementation context [12]. The findings of the present study further support this variability and indicate that transferring such interventions from NICU to home depends not only on selecting appropriate sensory stimuli but also on parental education and adaptation of the intervention to family circumstances.
Regarding behavioral interventions, programs such as the infant behavioral assessment and intervention program (IBAIP), were mainly based on Als’s synactive theory [24–27]. These interventions focused on educating parents to observe and interpret infants’ behavioral cues and respond appropriately. In these programs, parents are considered active participants in the intervention process, and improving parent-infant interaction while supporting infants’ self-regulation represents the primary pathway through which these interventions may exert their effects. This finding is consistent with recent evidence emphasizing the importance of family-centered care and the role of parent-infant interaction in developmental outcomes among preterm infants [11, 31]. Despite theoretical similarities among these programs, considerable variations were observed in the number of intervention sessions, time of initiation, follow-up duration, and level of professional involvement. Moreover, although programs such as the transmural developmental support for very preterm infants and their parents (TOP program) are structured and comprehensive, their implementation may be associated with practical and financial challenges due to the requirement for frequent home visits. Kynø et al. found that the mother–infant transaction program (MITP) did not produce significant improvements in the cognitive, motor, or behavioral outcomes of preterm infants [10]. This discrepancy compared with other studies may be related to differences in intervention intensity and duration, time of initiation, follow-up period, participant characteristics, and assessment tools. These findings suggest that relying on a shared theoretical framework alone does not necessarily produce consistent outcomes; implementation characteristics and contextual factors may substantially influence the effectiveness of behavioral interventions.
Regarding family-centered interventions, studies primarily focused on empowering parents, improving their understanding of preterm infants’ characteristics and needs, increasing caregiving confidence, and improving the quality of parent-infant interaction [28–30]. Programs such as creating opportunities for parent empowerment (COPE) showed that targeted information and structured education can reduce parental anxiety and improve parents’ readiness to assume caregiving responsibilities [28, 29]. However, this review study indicated that some family-centered programs focused mainly on the NICU hospitalization period and provided limited continuity after discharge. In contrast, the positive parenting program (triple P) for infants provided a broader framework for parenting support; however, implementing it across different healthcare settings requires cultural adaptation, appropriate service infrastructure, and sufficient resources [30]. Furthermore, evidence suggests that the effectiveness of these interventions depends not only on educational content but also on continuity of support and active parental involvement after discharge, which are key factors in successful implementation [31].
From a theoretical perspective, the reviewed interventions were based on diverse frameworks, including neurodevelopmental theories, motor learning theories, the synactive theory, and family-centered care principles. However, some studies did not clearly describe the theoretical foundations underlying the interventions. Outcomes also varied widely, with studies assessing motor, cognitive, and behavioral outcomes, as well as parent-infant interaction and parental psychological indicators. These findings highlight the multidimensional nature of post-NICU discharge developmental supportive interventions, suggesting that their effects extend beyond infant development alone and include family and psychological dimensions. The present study complements previous review studies in several ways. Unlike the studies that primarily focused on intervention effectiveness [8, 9, 11, 31], this study employed a scoping review approach to systematically identify and classify interventions, their theoretical foundations, program components, and outcomes. Discrepancies among studies relate not only to intervention type but also to theoretical frameworks, implementation methods, and outcomes. By organizing existing interventions into four major domains, this study clarifies the structure and scope of post-NICU discharge developmental supportive care.
From a practical perspective, implementing the identified interventions in Iran requires careful consideration. Some programs, such as those involving repeated home visits by professionals or multi-stage interventions with long-term follow-up, require considerable human resources, time, and financial investment, making widespread implementation in resource-limited settings challenging. However, family-centered interventions based on parental empowerment, KMC, parental training to respond appropriately to infants’ behavioral cues, and play-activity based programs may have greater feasibility due to their lower costs, potential integration into routine post-discharge services, and reliance on active parental participation. Given the structure of the national healthcare system and the role of health centers in following up high-risk infants, family-centered and educational models may provide a practical and sustainable approach to expanding post-NICU discharge developmental care in Iran. Nevertheless, further national studies are needed to evaluate the feasibility, acceptability, and effectiveness of these interventions in the Iranian context.
The findings of this scoping review should be interpreted in light of several limitations. First, scoping reviews primarily map and describe available evidence; therefore, quantitative assessment of intervention effectiveness, including meta-analysis, was beyond the scope of this study. Second, although a comprehensive search was conducted across major electronic databases, grey literature including dissertations, research reports, unpublished studies, and conference proceedings, was not systematically searched. Consequently, some potentially relevant studies may not have been captured, and the presence of publication bias cannot be ruled out. Furthermore, limiting the search to articles published in Persian and English may have introduced language bias. Furthermore, although screening and data extraction were performed independently by two researchers, the potential for bias in study selection, classification, and interpretation cannot be entirely ruled out. Moreover, substantial heterogeneity among the included studies regarding participant characteristics, time of intervention initiation, intervention intensity and duration, extent of parental involvement, theoretical frameworks, and study outcomes limited direct comparisons across studies and hindered the identification of the most influential intervention components. In addition, some studies did not provide comprehensive details regarding the theoretical foundations, active components of the interventions, or implementation procedures. Finally, in line with the methodological framework of scoping reviews, the methodological quality and risk of bias of the included studies were not formally evaluated. Therefore, the findings of this review primarily reflect the scope, characteristics, and existing gaps in the evidence rather than the quality or magnitude of intervention effectiveness. Despite these limitations, this study offers a comprehensive overview of developmental supportive interventions for preterm infants after NICU discharge and may provide a basis for future research as well as the development of family-centered programs in this area.
Conclusion
Although post-discharge interventions for preterm infants are highly diverse, they should not be regarded as a fragmented collection of isolated techniques. In reality, discharge from the NICU does not mark the conclusion of developmental care, but rather the onset of a critical transitional phase into the home environment. Accordingly, instead of relying on purely descriptive approaches, healthcare professionals—including occupational therapists, physiotherapists, and nurses—are encouraged to adopt an integrated, phased, and synergistic clinical guideline. Within this framework, clinicians must evaluate the infant’s self-regulatory capacity prior to administering any physical intervention. If stress cues emerge, sensory regulation strategies should take precedence; targeted motor interventions ought to be introduced only when the infant achieves a quiet-alert state and physiological stability. Furthermore, the role of the clinical team must transition from direct service providers to coaches and facilitators, thereby empowering parents to independently implement these interventions into daily routines.
Statement on the use of AI tools
The authors used large language model (LLM) tools only for language editing and formatting support to improve readability and flow. The authors are responsible for all content, data interpretation, conclusions, and the final version of the manuscript.The authors declare that no AI tools were used for writing, data analysis, or generation of scientific content in this manuscript.
Ethical Considerations
Compliance with ethical guidelines
This study was approved by the research Ethics Committee of the University of Social Welfare and Rehabilitation Sciences, Tehran, Iran (Code: IR.USWR.REC.1403.210). Since this was a review study with no participants, there was no need for obtaining informed consent.
Funding
This study was funded by the University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
Authors' contributions
Conceptualization: Hajar Sabour Eghbali Mostafa Khan, Nazila Akbarfahimi, Farin Soleimani; Methodology: Hajar Sabour Eghbali Mostafa Khan, Nazila Akbarfahimi, Seyed Ali Hosseini; Validation: Hajar Sabour Eghbali Mostafa Khan, Seyed Ali Hosseini, Farin Soleimani; Analysis and investigation: Hajar Sabour Eghbali Mostafa Khan and Aida Ravarian; Writing the initial draft and visualization: Hajar Sabour Eghbali Mostafa Khan; Review and editing: Nazila Akbarfahimi, Seyed Ali Hosseini, Farin Soleimani, Aida Ravarian; Supervision: Seyed Ali Hosseini and Nazila Akbarfahimi; Project administration: Seyed Ali Hosseini. All authors read and approved the final version of the manuscript.
Conflict of interest
The authors declared no conflict of interest.
Statement on the use of AI tools
The authors declare that they have not used any AI tools for the content creation of this manuscript.