Robert White, MD, Director, Regional Newborn Program, Beacon Children’s Hospital (South Bend, Ind.), Newborn Brain Society – Education Committee
Babies enter the NICU during life’s most active stage of brain growth and learning which forces this crucial development to occur, for better or worse, in an environment that is far removed from the normal in utero experience. As our technological capabilities improve even higher-risk babies survive, such as those with extreme prematurity or hypoxic-ischemic encephalopathy (HIE). How should we nurture appropriate brain growth in the midst of an increasingly high-tech environment, and what role does the structural design of the NICU play in this effort?
The environment of care can influence the sensory experience of infants in multiple ways – it can provide an excess of noxious stimuli (e.g., noise, bright lights) or perhaps just as significantly, it can restrict the ability to receive stimuli through the extended intimate human contact which the baby would naturally experience in utero. Two elements, then, should be considered in any new NICU design and in modifying existing environments of care: reduction of noxious sensory stimuli and enrichment with nurturing sensory input.
Noxious stimuli abound in the typical NICU and are stressful not only for babies (even though they seem oblivious) but also for families and caregivers. Strong evidence has been available for many years of the adverse effects of the auditory environment in particular, but lighting and visual stimuli are important as well. With the advent of private rooms and electronic communications, ambient noise levels can be reduced to 45 dB or less as recommended by the AAP and sudden bursts of noise, as with alarms or traffic close to a baby’s bed, can be nearly eliminated. Reducing the “white noise” inside incubators and machine noise for babies on high levels of support (e.g., ventilators) remains a challenge not easily resolved by structural changes. Appropriate lighting, both electrical and daylighting, can be addressed by structural changes as long as the design team is familiar with the current evidence on optimal lighting for both babies and adult caregivers so their disparate needs can be met.
Concurrent with reducing noxious stimuli to a minimum, efforts to enhance the positive sensory input for babies should be undertaken. By far the most effective way to do this is to allow extensive intimate contact between parents and babies. To a large degree this requires changes in the NICU culture, both in terms of how families are welcomed and encouraged to participate in the care of their infant and in ways staff can provide important sensory input when families can’t or won’t. But structural changes can have a large impact as well, particularly in providing the space and support a family needs to spend extended intimate time with their newborn. In this regard, private or “single-family” rooms have been shown to improve neurological outcomes as long as families are actually there as the “active ingredient”. For babies whose families are not present, group care in small pods is probably optimal but there will still be an operational component needed to provide the necessary stimuli above and beyond routine feeding and diapering.
Finally, the design of a NICU conveys important principles to everyone who enters, family or staff. A bright, welcoming, spacious, and calm environment of care directly affects the psyche of adult caregivers and ultimately the care that their babies receive.