Newborn observation: a closer look

28 January 2017

Having a newborn at home is arguably one of the most challenging times in parenthood. But Sheffield-based health visitor Jessica Halliday discovered how using the newborn behavioural observation system can facilitate positive relationships between parents and infants.


Health visitors play a key role in supporting parents in adjusting to the transition of parenthood. We appreciate that this can be a challenging time, especially for those who suffer from postnatal depression, have a history of mental illness, feel isolated, have premature infants or indeed any parent who may be struggling with the care of their baby. We, as practitioners, understand that poor care in the early days, when the infant’s brain is developing rapidly, can lead to poor outcomes and high costs to society.

The importance of ‘attachment theory’ (Bowlby, 1982) and of more recent work on neurosciences and baby brain development has led to the ‘1001 critical days’ (Leadsom et al, 2013) being seen as a crucial time to help parents foster healthy relationships with their babies – and the earlier the better. It is recognised that good parenting sometimes requires professional help to facilitate attachment and positive, responsive interactions between parents and their babies. I have found that using the newborn behavioural observation (NBO) system in health visiting practice provides an excellent opportunity to help forge positive relationships between parent and baby and parent and practitioner. The 2015-16 National Health Visiting Core Service Specification (NHS England, 2014: 14) also recommends the use of the NBO as ‘an evidence-based, effective intervention’.

What is the NBO?
The goal of the NBO, developed by Nugent et al (2007), is to strengthen the relationship between parents and their babies, as well as to promote a positive relationship between practitioner and family. It was developed from (but can still be used to complement) Brazelton and Nugent’s Neonatal Behavioural Assessment Scale (NBAS) (1995). The NBO differs from the NBAS as it shifts the practitioner’s role from assessment and diagnosis to observation and relationship building.

The NBO is a structured, neurobehavioural observation of the infant. It is delivered in collaboration with the parent and enables both parents and practitioners to describe and interpret the baby’s behaviour. It is this interpretation, in discussion with the parents, that enables practitioners to offer guidance on caregiving. Using the NBO, the clinical focus is on the baby’s individuality. It gives the baby a ‘voice’ through their behaviour, and helps the parent understand who their baby is, their preferences, strengths and challenges. 

In this way, the NBO helps to give parents and practitioners information about development and its meaning.  

The NBO consists of 18 neurobehavioural observations that need to be administered in the appropriate behavioural state. For example, a quiet, alert state is ideal for playing, learning and feeding. There are six behavioural states: deep sleep (non-REM); light sleep (REM); drowsy; quiet alert; active alert (fussy); and crying.

The 18 neurobehavioural observations include the baby’s capacity to habituate to light and sound, their motor and activity level, capacity for self-regulation, response to stress, and visual, auditory and social interactive capabilities:

  • Habituation to light
  • Habituation to sound
  • Muscle tone
  • Rooting
  • Sucking
  • Hand grasp
  • Shoulder and neck tone
  • Crawling response
  • Response to face and voice
  • Visual response (face)
  • Orientation to voice 
  • Orientation to sound
  • Visual tracking
  • Crying
  • Soothability
  • State regulation
  • Response to stress: colour changes,
  • tremors, startles
  • Activity levels.

Some babies will be able to habituate to light and sound easily (such as protect their sleep), fix and follow, demonstrate clarity of states and smooth transitions between states, self-soothe and be consoled easily. Other babies may show unclear states, find it hard to locate stimuli, avert their gaze frequently and require limited stimuli, or be hyper-alert and difficult to console. And others may show a mixture of these behaviours.

The list of 18 items enables the parent and practitioner to understand the baby’s individual abilities and behaviours, as well as their stress signals – occasions when the baby is easily overwhelmed with stimulation and needs a break. It is the degree to which the baby organises these behaviours and attempts to self-regulate that is the focus of the NBO. The tool can also offer the opportunity to validate a parent’s observations, share concerns and identify appropriate caregiving strategies. It can promote a positive relationship as the parent develops trust in a practitioner with the care of her baby and him or herself.

Unique cues
The NBO provides individualised guidance to parents. Advice from parenting books on sleep, feeding and crying, for example, can sometimes be unhelpful because it can distract the parent from reading the communication cues of their own baby, and from appreciating that the baby requires individualised responses. The NBO aims to promote the parent’s attunement with their baby in order to understand his/her individual needs. As Gerhardt (2015: 34) states: ‘Well-managed babies come to expect a world that is responsive to feelings and helps to bring intense states back to a comfortable level; through the experience of having it done for them, they learn how to do it themselves.’

The flexible nature of the NBO means it can be used whenever a health practitioner feels it would be beneficial. I have found that the tool can easily be incorporated into the new birth and/or six-week visit.

Counting the cost
The economic benefits of early intervention are well documented. Health Education England recommends that every health visiting service should have a specialist health visitor for perinatal and infant mental health (Rance, 2016). A specialist role to take a lead in this area is both welcome and important, as all health visitors are ideally placed to strengthen the infant-parent relationship. Being trained in the use of the NBO (a two-day course) can increase the health visitor’s knowledge of baby development, while offering a greater understanding of the needs of parents. 

Although local authority funding cuts may necessitate changes in health visitor service delivery, I suggest that incorporating the NBO into an attachment model of health visiting could be possible at little cost. All NBO-trained health visitors could include it within current practice to complement and enhance the invaluable service we already offer in preventative intervention and the promotion of infant mental health. 


Julie is a first-time mum to Jack, born weighing 4kg. She is a teaching assistant on maternity leave while her husband works in IT. Julie has a history of depression. Both parents were excited at the prospect of having a baby and Julie said that she planned to breastfeed.

At the new birth visit both parents looked exhausted. Julie was exclusively breastfeeding and Jack was gaining weight. But Julie was anxious and tearful and said she didn’t enjoy the ‘constant breastfeeding’.

Jack was awake and being passed between the parents as they tried to settle him. The parents wondered whether he had colic or reflux as he was often fussy. They told me they didn’t know why he was crying as they had ‘tried everything’. Dad left to go to the chemist and I had a chat with Julie. She explained she was finding it difficult to settle Jack and she was worried that he wasn’t developing normally. She also said that she was concerned that Jack didn’t look at her very often or for very long. I suggested we had a closer look at his behaviour and what he was telling us using the NBO system. Julie agreed to this.

We proceeded to go through each of the 18 items, (missing the first two as Jack was awake) eliciting, describing and interpreting Jack’s behaviour. Throughout the session, relaxed, responsive handling of Jack was modelled to Julie. Julie was interested to watch and learn about Jack’s strong muscle tone as seen in the spring-back of his arms and legs and also see his rooting and sucking response.

We talked about how his hand grasp was strong and how she enjoyed playing with his hands while he was feeding. This provided the opportunity for us to discuss the positive effects of touch and skin-to-skin contact on breastfeeding and on the mother-infant bonding process.

Julie brightened gradually throughout the session and seemed interested in discussing the developmental achievements of Jack and the meaning of his behaviour. She seemed pleased to observe how Jack could hold his head up when he was supported well while sitting. We observed Jack briefly follow a red ball and Julie became animated as he responded to her face and voice. As the NBO was incorporated into the new birth visit, safe sleep was discussed when we placed Jack on his stomach to observe his crawling response. We noted how quickly Jack started to cry. Undressing, weighing and measuring Jack provided the opportunity to observe his response to stress as seen in his mottled skin, gaze aversion and startles. We took a few moments to observe his attempts to self-soothe. I modelled gentle talking to Jack, placed my hand on his stomach and then held him while we talked about how Julie could support him next time he cried. 

When I began the visit, Julie was feeling unconfident and disengaged with her baby: a mum who was visibly stressed and anxious. During the NBO session, I believe that I had started to help Julie see Jack in a different light – as an individual with amazing potential, who was forming a positive relationship with her.

At the follow-up visit, Julie looked happier and more relaxed. She was more able to read his cues and settle him in a relaxed, responsive manner and she was enjoying breastfeeding. At six weeks, Jack was asleep and we were able to see him habituate to light and sound. As he woke up, I observed a smooth transition through the behaviour states and his ability to self-soothe. Julie said that she enjoyed the NBO because she learned things about Jack’s development and temperament, which helped her manage his care, and she felt like she understood him better. 


Brazelton TB, Nugent JK. (1995) The neonatal behavioural assessment scale. McKeith Press: London.

Bowlby J. (1982) Attachment and loss: volume 1: attachment. New York: Basic Books.

Gerhardt S. (2015) Why love matters. How affection shapes a baby’s brain (second edition). Routledge: New York.

Leadsom A, Field F, Burstow P, Lucas C. (2013) The 1001 critical days: the importance of the conception to age two period: a cross-party manifesto. See: 1001criticaldays.co.uk/sites/default/files/1001%20days_Nov15%20(00000002).pdf (accessed 6 December 2016).

NHS England. (2014) 2015-16 national health visiting core service specification. See: england.nhs.uk/wp-content/uploads/2014/12/hv-serv-spec-dec14-fin.pdf (accessed 6 December 2016).

Nugent JK, Keefer CH, Minear S, Johnson LC, Blanchard Y. (2007) Understanding newborn behavioural observations (NBO) system handbook. Paul H. Brookes: Baltimore.

Rance S. (2016) Specialist health visitors in perinatal and infant mental health: what they do and why they matter. See: hee.nhs.uk/sites/default/files/documents/Specialist%20Health%20Visitors%20in%20Perinatal%20and%20Mental%20Health%20FINAL%20low%20res.pdf (accessed 6 December 2016).

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