1/11/23

The Brazelton Institute

Boston Children's Hospital

Newborn Behavior
Observations (NBO)
System

NBO Step by Step

Module 2

Learning Outcomes

• Administer the 18 items

During this session • Follow the infant’s lead
you will learn to:
• Support the parent-infant and parent-
practitioner relationships

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The Blue Card

Administering the NBO

Used with infants up to three months of age (or corrected age for preterm
infants)

Items include:
• Habituation to light and sound (sleep protection)
• Muscle tone in legs and arms, shoulders and neck and Activity Level
• Reflexes: rooting, sucking, hand grasp, and crawling
• Visual and auditory responsiveness: to face and voice, red ball, rattle
• Crying and soothability
• Response to stress

1 - Deep 2- Light 3 - Drowsy 4 – Alert 5 - Active 6 – Crying

sleep sleep • Eyes may be open • Bright-eyed look alert • Intense crying
but dull and heavy and their motor which is difficult to
• Regular breathing • Eyes closed lidded, dazed look, activity will be • Eyes open, break through
• Eyes closed and • Rapid eye closed or minimal considerable • High motor
no eye movement often fluttering eyelids motor activity
• Able to focus their activity
movements observed under • Variable activity attention on visual • Brief fussing
• No spontaneous closed lids level, responses or auditory stimuli vocalizations
movements • Low activity level often delayed and
except startles and sucking motor activity at a
movements can minimum
occur • Can be waking up
• Breathing may be or may go back to
irregular a deeper sleep
state

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Before you begin – Being Mindful

• Attend to your own emotional state before you meet the baby and
family. How do you let go of other concerns?
• How do you create a safe psychological space for parents?
• Take time to “set up”... a place for everyone to see the baby, to sit, with
your tools within reach, a blanket, a pacifier (if used by parents).

Be Flexible: Respect the Baby

The order of item

presentation depends on the
state of the baby

The items included in the

NBO depend on the situation

The “Ideal” NBO Setting

Baby Environment
• Fed • Lights are dimmed
• Baby is in the center
• Asleep • Caregivers are sitting close and
• Not in pain from recent comfortably to observe and interact
painful procedures (e.g. with the baby
immunizations, heel stick)

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The “real” setting:

• Of course, conditions are rarely ideal
• The baby’s state and the conditions in
the environment will determine how the
session begins and will moderate the
flow of the NBO

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Introducing the NBO to the family

• Briefly outline the NBO and the goal of the session
• Set the collaborative stage for the session
- e.g. “Let’s look at your baby’s behavior together. Let’s see what we
can learn about her individuality, what she likes to do and what she is
telling us about herself.”
• See Page 61 of Handbook for examples
• Remind caregivers that their baby may fuss and cry during the NBO, but
nothing we do is painful.

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Introducing the NBO to the family

• Be attentive to the caregivers’ concerns and reactions to the NBO.
• Use this time to begin to establish a relationship with the caregivers by
asking them about their baby and talking/introducing yourself to the
baby.

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NBO
Step by Step
One item at a time

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Initial Observation
Spend approximately 30 seconds at the start of
the NBO quietly observing the baby:
• State
• Perfusion of the skin
• Activity level
• Any tremors, sudden movements, startles,
etc.
See Page 65 of Handbook

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Habituation

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Habituation to light
Shine light briefly over the baby’s closed
eyes at approximately 5 second intervals

See Page 69 of Handbook

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Habituation to light
Observe the baby’s response to the stimulus
(e.g. body movement, facial grimace, etc.)
Present stimulus up to 10 times or until the
baby does not react to the stimulus two
consecutive times

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Habituation to sound
Give a brisk three-time shake of rattle
approximately 12 inches (30cm) above the
baby at about 5 second intervals

Present stimulus up to 10 times or until no

response two consecutive times

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Motor Items

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Uncover and undress

Adjust the baby’s position to supine (lying on back).

Remove blankets, and remove clothing as appropriate,

depending on setting, warmth of the room and the
baby’s reactions so far.

Observe response, including state change, autonomic

changes, activity.

See Page 75 of Handbook

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Tone: Arms and legs

Gently flex and extend, in turn, lower and
upper extremities.

Observe the quality of the tone.

Observe the “recoil” when you release

extension.

See Page 77 of Handbook

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Rooting
Position the baby’s head in midline.

Stimulate the corner of the mouth with a

gloved finger.

Observe for turning, tongue extension, and

opening of mouth.

See Page 80 of Handbook

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Sucking
Place your finger, palm up, in the baby’s
mouth.

Observe strength and rhythmicity of suck.

Observe the effect of sucking on the

baby’s regulation.

See Page 82 of Handbook

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Hand grasp
Place your finger on the palm of the infant’s
hand and observe the grasp reflex. Avoid
touching the back of the hand (inhibits
reflex).

Note strength and quality of grasp.

See Page 85 of Handbook

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Shoulder and neck tone (pull to sit)

Beginning with the baby in the supine position, grasp their hands
and pull up to sitting position. Add support to stabilize shoulders
as needed.

At eye level, speak to the baby to encourage them to lift their

head and hold in midline.

Observe:
- head lag
- bringing head to midline
- keeping head at midline in sitting position

See Page 87 of Handbook

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Crawling
Place the infant in the prone position (on
tummy) with their arms bent up towards
head on either side of trunk.

Observe for crawling motions of arms and

legs as well as ability to lift and turn head
to free airway.

See Page 90 of Handbook

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Social Interaction & Responsivity

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Response to Face and Voice

When the baby is in a quiet alert
state, hold baby in front of you
about 12 inches from your face, at
a 60˚ angle from supine.

If necessary, use the NBO

comfort/alerting measures to help
the baby settle and maintain baby
in quiet alert state.

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Response to Face and Voice

Attempt to catch baby’s attention
in midline (face to face) by
speaking to them with an animated
expression.

While continuing to speak, move

smoothly from midline, first
laterally (left and right), then
vertically upward.

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Response to Face and Voice

Modulate the sound levels of your
voice to optimize baby’s response.

Observe response and check for

stress or “cost” signs.
See Page 92 of Handbook
Be aware of signs of
disengagement

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Visual response to Face

• Hold baby at 60˚angle facing you
• Attempt to catch the baby’s attention in
midline using just facial expression
• Move your face slowly from midline, first to
right and left, then vertically upward

Remember to be responsive to the baby’s own

rhythm and pace when interacting

See Page 97 of Handbook

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Orientation to Voice
• Hold the baby so you are out of their
visual field
• Call the baby from one side of their
head, modulating your voice to optimize
response
• Alternately, ask the caregiver to call the
baby
• Observe
– stilling and brightening

– turning to locate source of sound

See Page 98 of Handbook

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Orientation to Sounds (Rattle)

• Hold the baby so you are out of their
visual field
• Shake the rattle on one side of the
baby’s head, then the other
• Modulate and vary the sound of the
rattle to optimize the baby’s response.

See Page 101 of Handbook

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Visual Tracking (Red Ball)

• Hold the baby at 60˚angle in front of you
• Keep your own and the caregiver’s face out
of baby’s field of vision.
• Attempt to catch the baby’s attention in
midline using the red ball
• Adjust distance of ball from baby’s face to
optimize their response.

See Page 103 of Handbook

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Summary Items

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Crying
Observe the amount and intensity of
crying over the course of the NBO.

What maneuvers of the NBO elicit

crying?

See Page 106 of Handbook

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Soothability
When the baby cries, offer consoling maneuvers in a
stepwise progression but first wait to see if the baby is
able to console by themselves.

1. Look at and talk to the baby.

2. Continue talking and place your hand on their belly.
3. Hold their arms and legs.
4. Pick them up.
5. Rock them.
6. Swaddle them.
7. Give them something to suck.

See Page 112 of Handbook

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State regulation
Take note of the states that the baby
moves through during the NBO.
How abruptly or smoothly do they
change from state to state?

How “readable” is the baby? That is, how

easy is it to tell what state the baby is in
at any given time?
See Page 116 of Handbook

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Response to Stress
Color, tremors & Startles
• What signs of autonomic stress does the baby
show?
- Primary examples include: loss of tone, color
changes (mottling, perioral paling), gagging,
respiratory changes, tremors and startles.
- Secondary examples are: hiccups,
sneezes, or yawns.
• What was the baby’s tolerance or threshold to
stimulation?

See Page 118 of Handbook

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Activity Level

Observe the level and quality of the baby’s activity throughout the NBO.
See Page 123 of Handbook

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NBO Recording form

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NBO Narrative Form and NBO Parent Summary form

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Summary
• Be flexible. Start with the baby, the baby’s state and the parent’s
responses guide the session.

• Practice the items until you reach the point where you can focus on
observing the baby’s responses and the parent’s engagement.

• Always consider how you are using the NBO items to build parent
understanding and confidence in reading their baby’s behavior

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