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CHAPTER 13 The Neonate and the Environment Impact on Development
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FIGURE 13.4 Premature infant hypotonic resting posture exhibiting the W configuration of arms, frog-leg position of the legs, abducted hips,
externally rotated ankles, everted feet, and asymmetric head position. This position promotes positional deformities and developmental gaps and
delays. (From Hunter J. The neonatal intensive care unit. In: Case-Smith J, ed. Occupational Therapy for Children. 4th ed. St Louis, MO: Mosby, 2001.)
369
BOX
13.10
1. Inhibits or shortens dystonic phase while infant remains in fetal
2. Facilitates hand-to-midline and midline orientation
3. Stimulates visual exploration of environment (through head to midline)
4. Facilitates development of head control (making feeding easier and
5. Helps balance flexors and extensors to facilitate symmetric
6. Helps develop antigravity movement
7. Enhances comfort and decreases stress
8. Has an organizing effect that facilitates development of flexor tone
9. Promotes normal and prevents abnormal development
10. Helps enhance development of motor skills, reflexes, and postural
From Pelletier-Sehnar JM, Palmeri A. High-risk infants. In: Pratt PN, Allen AS, eds.
Occupational Therapy for Children. 2nd ed. St Louis, MO: Mosby; 1989.
REASONS FOR PROPER POSITIONING
position during postnatal period
helping respiratory problems)
288,297,370
posture
297,370
tone
112
112
112
112,370
ventilation or CPAP) had their end-expiratory
levels and ventilation distribution measured at 30
minutes, 2 hours, and 4 hours after repositioning.
186
The three body positions used during the study
were prone, quarter turn from prone, and supine.
Spontaneously breathing infants had better ventilation homogeneity 2 hours after repositioning
and global end-expiratory levels at 4 hours.
Infants receiving both CPAP and mechanical
ventilation had improved ventilation homogeneity at 2 hours after repositioning that continued
to be maintained at 4 hours. Those infants on
CPAP had an improved global end-expiratory
level at 2 hours after repositioning.
Side-lying is used to improve visual awareness of hands, encourage hands-to-midline
movement, and discourage the frog-leg position.
In this position, the infant can bring the hands
to the mouth for sucking and self-comforting.
Side-lying is best maintained with swaddling or
commercial positioning devices rather than single
blanket rolls (Fig. 13.5). Position extremities so that
the bottom arm is in a comfortable position and
the upper shoulder and hip are slightly forward of
the weight-bearing lower hip or shoulder, provide a
small roll (e.g., folded cloth diaper or washcloth or
small bean-stuffed toy), and bundle for security but
not so that the upper extremity compromises chest
expansion. Alternating sides reduces head molding and may prevent atelectasis of the dependent
lung. The head and trunk should be maintained in
neutral alignment (e.g., the head and trunk are in
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FIGURE 13.5 Small preterm infant in side-lying position supported in flexion and with a midline orientation of the extremities. (From
Hunter J. The neonatal intensive care unit. In: Case-Smith J, ed. Occupational Therapy for Children. 4th ed. St Louis, MO: Mosby, 2001.)
the same vertical plane). The left lateral position
has been shown to improve oxygenation, lung
mechanics, and breathing patterns in preterm
infants, similar to the benefits of prone position-
159
ing.
However a recent study showed that lateral
positioning of preterm infants (median gestational
age of 28.6 weeks) receiving nasal CPAP resulted
in increased respiratory rates.
460
Left lateral position reduces gastroesophageal reflux, whereas right
lateral position reduces gastric residuals.
118
Longer
sleep duration and less wakefulness in preterm
infants occur when they are positioned flexed in
the lateral position compared to lateral positioning
without flexion.
421
To accommodate their ventilators, umbilical
catheters, and other devices, acutely ill preterm
infants may be positioned supine; the preterm neonate’s head should be in the midline. Positioning
VLBW infants supine with their heads turned to
either side causes mechanical obstruction of cerebral
venous return and alters cerebral blood flow, which
may contribute to the development of intraventricular hemorrhage (IVH).
330
Cerebral (and mesenteric) tissue oxygenation was recently measured in
clinically stable VLBW infants in two supine positions (i.e., with head tilted up 30 degrees and lying
flat) and prone (lying flat).
103
Regardless of position
these stable VLBW infants were able to maintain
stable cerebral and mesenteric tissue oxygenation,
both before and after feeding.
103
Supine positioning does not promote flexion
and may be stressful to acutely ill infants. Earlier
studies found an increase in apnea, bradycardia, and
periodic breathing in supine positioning, although
a more recent study of 22 preterm infants with
apnea and bradycardia found no significant difference in the incidence of clinically significant events
between supine and prone positioning.
202
Placed
supine, infants exhibit more startle behaviors, agitation, motor disorganization, calorie expenditure,
and sleep disturbance (higher number of arousals/
284
hour)
from environmental stimuli.
Prolonged supine positioning is associated
with the hypertonic “arched” position (hyperextension of head, neck, and shoulder girdle)
of many chronically ventilated infants (Fig. 13.6) .
Use of a gel or water pillow under the infant’s head
and neck (e.g., to the nipple level to prevent neck
flexion or used as a mattress under the head or body
of a VLBW infant) provides comfort and maintains
neutral alignment.
Supine positioning should promote as much
flexion as possible. Use of a positioning device
of foam with the middle cut out and sloping
under the scapulae is another method of obtaining
supine flexion. Use of hip support results in less
lower extremity abduction and external rotation
than in infants without such hip support. Pillows
filled with polystyrene beads (i.e., preterm beanbags) require skill for optimal positioning and
CHAPTER 13 The Neonate and the Environment Impact on Development
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FIGURE 13.6 Supine positioning without positioning supports results in motor disorganization, agitation, arching posture, and burning
of significant calories. (From Hunter J. The neonatal intensive care unit. In: Case-Smith J, ed. Occupational Therapy for Children. 4th ed. St
Louis, MO: Mosby, 2001.)
371
close infant monitoring but are useful in providing positioning for very small premature infants
(1000–1500 g).
Body containment increases the infant’s feeling
of security, promotes quieting and self-control,
enhances physiologic stability, promotes energy
conservation, reduces physiologic and behavioral
stress, and enables stress to be better endured.
402
Without positional supports, many premature infants
“travel” (no matter how many times they are returned)
to the sides or bottom of their incubator. Parents and
professionals are inclined to move the uncomfortable-looking infant back to the middle of a “boundary-less” world. Infants should be left where they feel
safe and comfortable; if they become uncomfortable,
they will let you know. Providing boundaries (e.g.,
blanket rolls, positioning devices) stops this
migration and the expenditure of precious calories
that could go to growth. Use of a conformational
positioning device that provides containment,
boundaries, and security facilitates better sleep in
preterm infants with less active awake time and
crying when compared to a standard mattress.
216
Small, acutely ill premature infants who are positioned supine are often extremely agitated, thrashing
arms and legs, tachycardic, and expending precious
energy and calories. Instead of needing medications,
these infants often are calmed by providing a nest
of blankets or a commercial nesting device (which
simulates the boundaries and security of the uterus).
This artificial womb must be closely surrounding
the infant to promote flexion, security, and quiet
rest (Fig. 13.7). If agitation recurs, a limb (usually a
leg) has extended outside the infant’s secure boundary; flexing and returning it to the “womb” quiets
the infant.12 Nesting and swaddling premature
infants increases both total sleep and quiet sleep
2
time.
Body containment maneuvers such as swaddling, holding on to a finger or hand, and crossing the infant’s arms in the midline and holding
them securely help with self-regulation during
feeding, procedures, or other stressful manipulations.91 A recent study of swaddling found wide
variation in the positioning of the neonate’s arms
and legs.
140
Safe swaddling includes position-
ing the baby’s extremities in slight flexion and
abduction. Placing an infant’s hips and knees in an
extended position with swaddling increases the risk
of hip dysplasia and dislocation.
189
Because being
wrapped in a blanket with extremities flexed simulates in utero position, swaddling (1) improves flexed
posture and flexor muscle tone, (2) facilitates behavioral responses, and (3) improves the development of
primitive reflexes. Swaddling is associated with a
small but significant risk of sudden infant death
syndrome (SIDS) when infants are placed on
their backs for sleep, and swaddled infants placed
prone have the highest risk of SIDS. Swaddling
is used most often in young infants to reduce crying
and should not be initiated in infants older than
4 months of age; it should cease when an infant
attempts to turn over and be completely stopped by
6 months of age.
329
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FIGURE 13.7 Very small premature infant resting quietly in a “nest” of pads and blankets.
Picking up the preterm infant from a supine
position often produces startles, apnea, or head hyperextension. A better technique is to roll the infant
prone, which flexes the head, and then flex the limbs
onto the trunk and pick up the infant. If the infant
has difficulty breathing in prone position, swaddle or
contain the extremities before picking up the infant.
Prone positioning encourages the infant to work
on using neck extension and promotes flexion of the
extremities. Devices for prone positioning include a
small hip roll or sling to assist in maintaining flexion,
use of gel/water pillows for head support, and secure
lower boundary for foot bracing. Use of a rolled
cloth or gel pillow placed under the infant (from top
of the head to the umbilicus) (1) provides elevation
of the body to promote extremity flexion without
placing excessive pressure on the knees and elbows,
(2) enables the shoulders to round forward over the
top of the roll, and (3) enables the legs to flex over
the bottom edge of the roll. Prone (versus supine)
positioning has numerous benefits and is the
position of choice for many NICU infants (Box
13.11). The semi-prone position (¾ turn) decreases
the variability of respiratory rate in preterm infants
(median gestational age of 28.6 weeks) receiving
nasal CPAP.
been shown to improve oxygenation of premature
infants on CPAP.
463
The quarter-prone position also has
420
To improve sleep duration
and quality, nurses are encouraged to assess each
BOX
13.11
1. Decreases heart rate variability
2. Improves oxygenation by 15% to 25%
a. Increased TcPo2 values
b. Increased Pao2 values
c. Decreased apnea, bradycardia, and periodic breathing
d. Increased peripheral oxygenation and decreases cerebral blood
e. Decreases respiratory rate
3. Improves lung mechanics and lung volumes
a. Increased lung compliance
b. Increased tidal volume
4. Decreases energy expenditure
a. Increased quiet sleep; higher arousal threshold
b. Decreased awake time; more sleep time
c. Decreased caloric expenditure (median difference supine vs.
d. Decreased heat loss
e. Less crying
f. Lower levels of activity
g. Lowers stress levels as measured by a reduction in salivary corti-
5. Decreases (by 50%) gastric residuals in the first 30 minutes after
6. Decreases gastroesophageal reflux
EFFECTS OF PRONE POSITIONING
37
flow
prone: + 3.1 kcal/kg/day)
77
69
sol levels
81
feeding
69
157
77
77
39,159,357
159,423
194
69,77,194,284
118
CHAPTER 13 The Neonate and the Environment Impact on Development
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373
individual preterm and more often use the position (prone vs. supine) that results in the least
arousals.
284
Sleeping in the prone position does
not improve oxygenation in preterms 32 weeks’
PMA or older for infants without respiratory
problems. The study concluded that preterms older
than 32 weeks’ PMA and without respiratory difficulties should be placed supine and monitoring
continued to ensure adequate oxygen saturation.
Use of a sheepskin or lambskin helps to further facilitate flexion and prevents skin abrasion, especially on
the knees.
Sleep Position. The most recent American Aca-
demy of Pediatrics (AAP) position statement on
infant sleep states that healthy infants should
be placed only in the supine position for sleep
beginning immediately after birth.
294
Infants
should sleep in their own beds and in the same room
with their parents for at least 6 months and preferably for the first year of life. Overheating sleeping
infants; use of soft sleeping surfaces, stuffed toys, and
positioning devices
418
; and inappropriate sleep environments (e.g., waterbeds, pillows, blankets, bumper
pads, bed railings, bed sharing, and sitting/carrying
devices)
infants.
88,148,355,375
294
Use of a pacifier for sleep and sleeping
should all be avoided in healthy
in proximity (same room) as parents is also recommended.
294
The Study of Attitudes and Factors
Effecting Infant Care (SAFE) collected prospective
data from a nationally representative sample of postpartum mothers about the intended sleep position
and the actual positions infants were placed in for
sleep.88 Although approximately 70% of the mothers
queried usually placed their infants to sleep supine,
less than 44% who intended to use supine position
actually placed their infants supine in actual practice.
African American mothers and mothers with less
than a high school education were more likely
to intend to use prone or side-lying position.
When advised by a doctor to use only supine positioning, mothers were less likely to use prone and
side-lying for infant sleep.
88
Use of side-lying and prone positioning, as well
as containment with soft bedding for physiologically compromised term and preterm infants, is
safe and appropriate in a NICU setting. Parents
may question these practices; therefore, their physiologic base and rationale should be explained.
Parents should be taught that when their baby
is medically stable, by 32 weeks’ PMA,
294
he
or she will be physiologically and developmentally mature enough to tolerate supine sleep
position in preparation for discharge.
232
Many
of the beneficial effects of prone positioning
listed in Box 13.11 are no longer necessary
232
and become detrimental in increasing the risk
for SIDS in the stable, mature preterm infant.
Since the “Back to Sleep” campaign, the rate
of SIDS has decreased by 53%,
294
but the SIDS
rate in the United States (US) has minimally declined
since 1999, and approximately 3500 sleep-related
deaths occur in the US each year.
49,121
SIDS rates
are inversely associated with gestational age,
and the risk of SIDS is three times higher in
preterm infants.
168,315
VLBW infants (<1500 g),
the group at highest risk for SIDS, have been
found in one study to be more likely to sleep
prone after discharge than larger LBW infants.
428
Reasons cited by mothers included infant’s preference and advice from professionals (NICU doctors,
nurses) who may remain uncomfortable recommending supine sleep in this population
232,428
despite
the AAP recommendations and the research that
supports them
294
(Table 13.9). Among families with
triplets and quadruplets, less than 80% of mothers
used supine for sleep immediately after hospital discharge; use of supine positioning decreased over time,
especially during daytime napping; 30% shared a bed
with siblings; less than 50% slept in the parents’ room;
and use of a pacifier was low.
167
Implementing “Safe Sleep” (“Back to Sleep”)
principles in the NICU remains a problem and
influences parental behavior.
32,300,328
One study
found that NICU nurses only followed safe sleeping
practices 20% of the time before an evidence-based
program promoting safe sleep began; after the
implementation of the program safe sleep practices
were used 90% of the time.
461
Nursing education
with web-based learning and in-person teaching
sessions improved compliance in safe sleep practices
in two level III NICUs from 25.0% to 79.7%.
187
Another project to develop a safe sleep educational
program and increase the percentage of eligible
infants in a safe sleep environment in the NICU was
conducted.
435
The process included a revised policy,
educational updates for NICU staff, an educational
packet and video for families, a wearable blanket,
and an observation checklist. From a baseline of
21% of eligible NICU infants experiencing a safe
sleep environment, safe sleep compliance increased
to 88%.
435
Quality-improvement initiatives that
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TABLE
13.9
SUPINE PRONE
Preterm infants at 36–38 wk PCA
No significant difference in sleep organization based on body position
More awakenings in supine vs. prone position
Standard deviations of heart rate increase during quiet sleep in supine
More sleep transitions, a lower arousal threshold, and higher heart rate
Full-term (n = 10) infants in prone/supine sleep positions given 0.4 mL
water; instillation into the mouth resulted in airway protective responses of
swallowing (95%) and arousal (54%)
Swallow rate rapid in supine position in response to small infusions of fluid,
whereas respiratory rate remains largely unaffected
When supine, term infants can coordinate rapid swallowing while
maintaining breathing
Full-term (n = 3240) ≥37 wk GA evaluated in the first 24 hr of life for
frequency/severity of spitting up incidents while asleep
• 96.6% did not spit up during sleep.
• 130 episodes of spitting up while sleeping supine (55%
• <4% spit up while sleeping supine, and none required
SLEEP POSITION AS A RISK FACTOR FOR SUDDEN
INFANT DEATH SYNDROME (SIDS): RESEARCH BASIS
157
position; low frequency and high frequency of heart rate higher in
supine vs. prone position in both active and quiet sleep states
variability while sleeping supine contribute to decreased vulnerability
to SIDS
195
400
:
required no intervention; 37% brief bulb suction; 6% gentle
stimulation; 2% wall suction).
significant intervention or experienced serious sequelae.
Prone position reduces spontaneous arousals from sleep in term
infants,
First quiet sleep after feedings significantly longer, fewer awakenings, and
decrease in overall heart rate variability in prone vs. supine
Preceding characteristics of prone sleep constitute a higher arousal
threshold, and thus increased vulnerability to SIDS in prone position
Decreased baroreflex sensitivity, which increases vulnerability to
hypotensive events
62 healthy, growing low BW infants (26–37 wk GA; 750–1600 g BW);
sleeping position—a shift of EEG activity toward slower frequency,
A significant decrease in swallowing and breathing in active sleep in prone
vs. supine position; airway protection is compromised in prone sleeping
Six episodes of spitting up while infants side-lying (66.7% no intervention;
33.3% bulb suction)
322,356
which may be related to a decrease in cerebral oxygen-
ation in prone sleeping
which may be related to mechanisms associated with a decrease in
behavioral arousal in prone position
position during active sleep in healthy term infants exposed to minute
pharyngeal fluid
456
157,356
322,356,456
459
356,366
BW, Birth weight; GA, gestational age; EEG, electroencephalogram; PCA, postconceptual age.
identify barriers, change hospital policies, and provide safe sleep education for nurses and parents are
needed to improve compliance with safe sleep recommendations for preterm infants.
In term infants, supine sleep position may delay
some motor milestones by 1 month but does not
delay walking. Increased amounts of time in supervised prone play (“tummy time”) encourage earlier
motor milestone attainment in supine sleepers and
helps prevent head molding. Head molding (i.e.,
bilateral flattening of the head and elongation of
the face) is a significant problem in preterm infants;
it results from flattening of the skull as the baby lies
against the firm incubator mattress. To parents, this
head flattening is concerning, and they may find
the infant less cute and desirable than a term infant
with a rounded head. To prevent head molding,
300
preterm infants are often placed on waterbeds,
water pillows, air mattresses, or eggcrate-type
mattresses, with varying results. Preterm infants
(<32 weeks’ gestation with birth weight <1500 g)
who are turned every 3 hours, repositioned in one
of six positions, and never placed in the same position twice in 8 hours had significantly rounder head
shapes from 9 to 13 weeks of life compared with
infants repositioned according to a standard NICU
procedure.
179
Kinesthetic. A combination of vestibular and
tactile stimulation increases quieting behaviors,
decreases apneic and bradycardic episodes,
entrains respirations, increases visual and auditory fixation, and increases brain growth.
210
Waterbeds provide contingent stimuli because
CHAPTER 13 The Neonate and the Environment Impact on Development
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375
they move in response to the infant’s movement;
oscillating waterbeds provide rhythmic motion.
Kinesthetic stimulation is provided by rocking
chairs, hammocks, baby swings, and baby carriers,
the effects of which have not been investigated. In
Brazil, a combination tactile/kinesthetic stimulation program enrolling 16 clinically stable preterm
infants under 2500 g was conducted and compared
with a control group of 16 preterms.
133
Outcomes
of the preterms receiving the tactile/kinesthetic
program included (1) higher daily weight gain,
(2) predominance of self-regulated behaviors (i.e.,
regular respirations, balanced tone, state of alertness, range of postures, coordinated movements,
hand-to-mouth movement control, suction, grip,
and support), and (3) a trend toward shorter length
133
of stay.
An RCT of parent-administered physical
therapy (promotion of head and postural control
and midline orientation) to preterm infants from
34 to 36 weeks PMA resulted in improved motor
performance at 37 weeks PMA when compared
to usual care.
419
Upright positioning in a car seat or infant seat
encourages symmetry and spatial orientation. Soft
rolls or foam padding maintains flexion; a rolled
blanket in a horseshoe configuration around the
infant’s head and shoulders prevents lateral slouching. Carrying quiets the infant, provides sensory
communication with the caregiver, changes the
infant’s environment, and provides visual, auditory,
and tactile stimuli. A nasal cannula (see Chapter
23) and portable tank enable mobility for an infant
receiving oxygen.
Rather than standardized protocols, tactile interventions must be individualized by assessing each
infant’s physiologic and behavioral responses before,
during, and after touch (see Table 13.6) . While an
infant is acutely ill, tactile intervention should
include minimal handling, containment, and
gentle touch (without stroking). As the infant
matures and becomes physiologically stable, stroking, rocking, and holding are integrated based on
the individual infant’s tolerance and preferences.
In healthy preterm infants, a program of range-ofmotion exercises with passive resistance is associated
with an increase in weight gain and growth, bone
mineral content and density, and muscle mass and a
decreased risk for osteopenia.
Cobedding. Cobedding, the practice of placing
239,430
medically stable twins and higher-order multiples
together in the same open warmer, incubator, or
crib, was initiated after the observed stress response
in separated siblings. The practice of cobedding
spread based on anecdotal information, because
there is limited research to support or refute
219
its use.
Few differences between cobedded and
noncobedded infants have been demonstrated. A
study of 117 sets of twins randomized to cobedding or sleeping alone found that cobedding promoted self-regulation (i.e., more time in the same
state, less time in opposite states, and less crying)
and more quiet sleep without apparent increased
175
risk.
Limitations of the research on cobedding
include small sample size, short follow-up periods,
lack of randomization, and blinding of evaluators.
Infection, safety, and parents continuing the
practice after discharge are major concerns of
cobedding. To date, increased infection rates in
cobedded infants have not been reported. Infection
concerns are addressed by good hand washing and
color-coding of equipment. Other safety concerns
include proper identification for medication administration and medical emergencies and maintenance
of temperature stability for all cobedded infants.13
Because parents continue care practices at home
that they have witnessed and become accustomed
to in the hospital, the possibility of continuing
cobedding at home (and the lack of evidence as to
its safety) must be considered.
The National Association of Neonatal Nurses
(NANN) recommends that a decision to cobed be
made with input from parents and should involve
education of staff and parents about potential benefits/risks, the experimental nature of the practice,
and the development of a clinical evaluation protocol to collect data on risks and benefits.
299
The AAP
recommends separate sleep areas in the hospital and
at home.
294
Both NANN
299
and the AAP
294
have
concluded that neither the safety or benefit
of cobedding has been established by current
research and that parents should be instructed
to follow established safe sleeping practices at
294
home.
AUDITORY INTERVENTION
The NICU is a noisy environment that has no
diurnal rhythm or predictability; it is as noisy at
night as in the daytime (Table 13.10).
102,158,269
An
infant in the NICU is exposed to an onslaught of
noise 24 hours a day for days, weeks, or months. At
follow-up, preterm infants exhibit a lower threshold
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for sound and a reduced responsiveness to auditory
stimulation.31 Assisted ventilation, severe asphyxia,
drug therapies, and possibly acoustic insult account
for the increased risk for sensorineural hearing loss
in NICU infants. The incidence of hearing loss
decreases with an increase in gestational age. An
increased risk of hearing loss is associated with
being born very preterm and late preterm.
180
Moderate to severe conductive hearing loss also
occurs in 42% of VLBW infants. Conductive hearing loss is attributed to endotracheal intubation,
poor eustachian tube function, increased otitis
media, and CLD in preterm infants.
The first goal in auditory intervention is to
assess the current level of noise in the NICU and
decrease the noise decibel level wherever pos-
269,340
sible.
The noise environment of an individual
infant depends on the type of NICU (single-family
rooms or open-bay), ambient sounds in the nursery,
the type of incubator and support equipment, and
the baby’s own behavior (e.g., quiet or crying).
Noise measurement protocols must sample multiple
noise sources and sites.
102,269
Some NICUs have
installed decimeters that present a flashing or blinking light when the noise level exceeds a preset level
(about 50–65 dB). Sources of noise include heating,
ventilation, and air conditioner flow units (noise
levels may decrease by 2.5–10.5 dB when these
units are turned off). The greatest contributor to
loud noise in the NICU is talking and conversation by the staff. Noise levels vary with type of
room, location, time of day, and day of week within
the NICU; therefore various locations or various
times and days should be measured.
102,269,340
Increased environmental noise levels are a
stressor to all infants in the NICU—preterm
infants and ill term infants (e.g., infants with
persistent pulmonary hypertension of the newborn or drug withdrawal) (Box 13.12). The sudden,
high-pitched, shrill, dysrhythmic noise of equipment
alarms alerts the care provider, but it also results in
infants manifesting an extreme hypersensitivity to
sound (as a learned conditioned response). CNSinjured preterms are particularly vulnerable to sound
stress in the NICU, are less able to habituate to
NICU noise, and respond with exaggerated and
prolonged physiologic responses (e.g., alterations in
respiratory rate, bradycardia, desaturations). Noise is
stressful not only to the infants but also to parents and care providers in the NICU.
38,176
Three
years after their NICU experience, mothers recall the
BOX
13.12
• Increase in stress behaviors:
• State lability
• Arousal state
• Avoidance behaviors—more fussy, more startles, etc. (see Table
• Sympathetic nervous system arousal measured by noninvasive
• Decrease in approach behaviors (see Table 13.4)
• Cardiorespiratory changes:
• Increased heart rate
• Increased respiratory rate
• Increased apnea or bradycardia
• Increased hypoxemia (decreased pulse oximeter)
• Increased peripheral and arterial vasoconstriction:
• Increased systemic blood pressure
• Increased intracranial pressure
• Increased sensory neural hearing loss
• Abnormal auditory development and processing
• Prevents habituation
• Alters development of sleep-wake cycles:
• Disturbs sleep; interrupts light sleep
• Even moderate noise disturbs sleep
• Increases wakefulness and agitation
• Increased risk for intraventricular hemorrhage:
• Increase in cerebral blood flow
• No change in cerebral oxygenation when peak sound levels
EFFECTS OF LOUD NOISE
13.4)
skin conductance, which was higher in male preterms
increased by 5 dB for short duration; cerebral oxygenation at
higher sound levels for longer durations unknown
368,436,452
119
noise level in the NICU as a stressor. NICU noise
is stressful to care providers and has the potential to
damage hearing; cause physiologic responses (e.g.,
increased blood pressure, altered immune response,
increased stress hormone secretion, disturbed sleep);
cause fatigue, irritability, and “burnout”; interfere
with communication with coworkers and parents;
alter concentration; and increase errors.
405
Although the AAP recommends that noise levels
be less than 45 dB,
448
most NICUs’ noise levels
range between 38 and 90 dB, with higher noise
bursts (see Table 13.10).* Recommended standards
for noise criteria have been established to protect
sleep, support stable vital signs, and improve speech
* References 71, 102, 147, 269, 340, 341
CHAPTER 13 The Neonate and the Environment Impact on Development
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TABLE
13.10
NOISE LEVELS IN THE NICU
LEVEL (DB) COMMENTS
48–69 Humidifiers and nebulizers
50–60 Normal speaking voice
a,b
50–73.5
Incubator (motor noise)
53 Median noise level on conventional ventilator
55–88
58–85
c
Bradycardia alarm
Noise in NICU (talking, equipment alarms, telephones, radio)
59 Median noise level on high-frequency oscillator
b
65–80
Life support equipment (ventilator; intravenous pumps)
66–76 Sink on/off
67 Incubator alarm
70
72.8–71.7
74–89.2
d
85
Background noise mean level should not exceed
Air conduction noise levels of jet ventilator, CPAP
Bone conduction noise levels of jet ventilator, CPAP
Noise level at which hearing damage is possible for adult; (?) neonatal effects
90 Peak sound intensity in the NICU not to exceed
d
90
92.8
b
Adult exposure for 8 hours requires protective device and hearing conservation program
Opening incubator porthole
84–108 Placing a plastic bottle of formula on top of incubator
b
96–117
70–116
80–124
b
b
Placing a glass bottle of formula on top of incubator
Closing one or both cabinet doors
Closing one or both portholes
120 Threshold for pain
b
130–140
160–165
d
Banging incubator to stimulate apneic premature infant
Recommendations for peak, single noise level not to exceed to prevent (adult) hearing loss; (?) neonatal effects
377
201
201
a
Modern incubators generate less than 60 dB; exceeds hourly recommendation of 50 dBA (see Table 13.11).
b
Measures from inside the incubator.
c
Noise levels do not vary from morning to night.
d
Occupational Safety and Health Administration (OSHA) standard. (No safety standards for neonates have been established.)
NICU, Neonatal intensive care unit.
Data from Thomas KA, Uran A. How the NICU environment sounds to a preterm infant: update. MCN Am J Matern Child Nurs. 2007;32:250.
intelligibility. Recent noise studies in NICUs have
found the following*:
• Noise levels are still louder than recommended.
• Environmental changes to reduce noise must be
monitored because they may increase rather than
decrease noise.
* References 4, 67, 71, 80, 102, 269, 340
• Nurses perceived their own NICU as “pretty
quiet” when, in fact, noise levels were above
recommendations.
• Noise levels have not significantly decreased in
the NICU.
• Single-room NICUs attenuate noise; there is
more silence. However, equipment noise and
noise from medical interventions is not decreased
in single-room units. Parent engagement and
presence is related to more language exposure.
UNIT TWO Support of the Neonate378
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TABLE
13.11
NOISE CRITERION RATIONALE
Hourly Leq (equivalent sound level) of 45 dB in infant room; 50 dB in staff
work areas
Hourly L10 of 50 dB in infant room; 55 dB in staff work areas (sound levels
may exceed 55 dB only 10% of the time or a total of 6 min/h)
L
max
imum decibel sound level ≤1 sec in duration—transient bursts of noise)
RATIONALE FOR SPECIFIC NOISE CRITERIA
of 65 dB in infant room; not to exceed 70 dB in staff work areas (max-
448
Preserves sleep for healthy term infants most of the time
Preserves sleep for infants; enables caregivers to speak at normal conversational levels and be clearly understood 12 feet away, approximately
90% of the time
Minimizes rousing babies and causing startle responses
• Initial and continued staff education is necessary;
monitoring and feedback every 2 to 3 months is
necessary
• Quality-improvement initiatives including education and behavioral and environmental modifications decrease noise in the NICU; constant
dialogue between champions and staff is required.
Table 13.11 presents specific noise criteria and
their rationale. Parents and care providers must be
involved in planning, developing, and being educated about quieter NICUs.
38,395
Strategies to minimize external auditory stimuli
include quieting alarms with suction (and remembering to reset them), not taking a shift report
over or allowing medical rounds near the infant’s
incubator, having noisy equipment repaired immediately, emptying sloshing water in ventilator or
nebulizer tubing, maintaining cardiac monitors in a
quiet state with alarms on (decreasing the sound of
alarms by 50%), and purchasing quieter equipment
(e.g., plastic instead of metal trash containers; quieter incubators). Choosing heated humidifiers (48
dB) rather than nebulizers (69 dB) and keeping the
containers full of water, rather than low, decrease
noise from respiratory equipment. Nursery design
changes
448
include smaller cubicles rather than
one large room, soundproofing materials, lights
for phones and alarm systems, and minimizing
equipment noise. Placing a blanket on top of the
incubator or using an incubator cover muffles the
noise of equipment placement; gentle, considerate
(to the infant) placement of equipment on or in the
(by medical, nursing, or ancillary personnel) on
the incubator Plexiglas should never be permitted. This (along with a brisk startle reflex from the
infant) is an opportunity to teach about the noise
levels generated by such activity. Infants should be
kept in incubators as long as necessary to maintain
heat balance. Older incubators do not protect
the infant from noise. A well-managed NICU
environment may be much quieter than the continuous noise of an incubator. Noise in modern
incubators varies according to the model. Sound
sources within an incubator include its motor, infant
sounds, equipment sounds inside the incubator,
equipment sounds transmitted from outside the
incubator, and ambient nursing noise (e.g., personnel, phones). Modern incubator walls attenuate
impulse noises from the NICU and may decrease
the infant’s noise exposure. Inside modern incu-
bators, motor noise does not exceed 60 dB, but this
level exceeds the more recent recommendation of
50 dB. However, impulse noises from the incubator
(i.e., doors, latches) are louder on the inside of the
incubator (see Table 13.10). Prolonged stays in an
incubator not only expose the infant to repeated
caregiving noises but also mean there will be a
dearth of kinesthetic stimulation (e.g., carrying,
holding, rocking, swinging, sitting upright in an
infant seat) and socially relevant speech patterns.
Both the internal noise generated by the incubator
and how well the incubator attenuates external noise
should be considered in incubator purchases.
incubator muffles sound; and closing portholes and
drawers gently decrease the structural noises of caregiving. Prohibiting placement of equipment (e.g.,
clipboards, stethoscopes, formula bottles) on top of
the incubator prevents such noises.
development of other sensory systems and delay the
development of hearing and language. Radios have
been banned in most NICUs. Day-night cycles
(naptime, nighttime) when auditory stimulation
Tapping (by parents or siblings) or banging
Noise levels in the NICU may interfere with
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