Preterm neonates in neonatal intensive care units (NICUs) rely on subtle behavioural and physiological cues to communicate comfort, distress, and self-regulatory needs. Understanding and responding to these cues is fundamental to developmentally supportive care and optimal neurodevelopmental outcomes. This integrative review explored the communication cues of preterm neonates in the NICU, assessed paediatric nurses’ knowledge of the Synactive Theory of Development, and examined environmental stimulants that induce stress in preterm infants. Guided by Russell’s framework and the PRISMA protocol, a systematic search of EBSCO, PubMed, ScienceDirect, and Google Scholar identified twelve eligible studies published between 2010 and 2023. The findings demonstrate that preterm infants consistently express hunger, stress, stability, and self-regulation through identifiable behavioural patterns, particularly during feeding and caregiving interactions. Recognition of these cues enables a shift from task-driven routines to co-regulated, infant-led care, resulting in earlier achievement of oral feeding, reduced length of hospital stay, enhanced parental involvement, and improved developmental trajectories. However, the evidence reveals persistent gaps in nurses’ knowledge and inconsistent application of cue-based care, especially in developing settings. Environmental stressors, including excessive noise, bright lighting, and invasive procedures, further destabilise fragile autonomic systems. The review underscores the need for structured education on cue interpretation and the integration of developmental care principles into routine NICU practice to improve outcomes and promote the long-term neurodevelopmental well-being of preterm neonates.

Keywords: Preterm neonates, Communication cues, Neonatal intensive care unit, Synactive Theory of Development, Developmental care, Cue-based feeding,

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