THE SENSORY ENVIRONMENT OF THE NICU: SCIENTIFIC AND DESIGN-RELATED ASPECTS

VOLUME 31 • NUMBER 2 • JUNE 2004 v

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Preface xiiiRobert D. White

Early Neurosensory Visual Development of the Fetus and Newborn 199Stanley N. Graven

Neurosensory development of the visual system has its originslong before birth. The genetic processes of basic structure formationare followed by endogenous retinal ganglion cell activation in theform of spontaneous synchronous waves of stimulation. Thesewaves of stimulation are required to establish the topographicrelationship among retina, lateral geniculate nucleus, and visualcortex. This process prepares the visual system for visual experience.Visual experience ultimately stimulates creation of columns ofneurons in the visual cortex, which are needed to see andinterpret patterns, lines, movement, and color. Spontaneous syn-chronous retinal waves occur in preterm infants in the neonatalintensive care unit and must be protected, as they are critical for visual development.

Emergence and Influences of Circadian Rhythmicity in Infants 217Scott A. Rivkees

Recent evidence shows that the circadian system of primate infantsis responsive to light at very premature stages and that low inten-sity lighting can regulate the developing clock. After birth, there isprogressive maturation of the circadian system outputs, with pro-nounced rhythms in sleep-wake and hormone secretion generallydeveloping after 2 months of age. Showing the importance of photicregulation of circadian phase in infants, exposure of prematureinfants to low-intensity cycled lighting results in the early estab-lishment of rest-activity patterns that are in phase with the 24-hourlight-dark cycle. With the continued elucidation of circadian

system development and influences on human physiology and illness, it is anticipated that consideration of circadian biology willbecome an increasingly important component of neonatal care.

Lighting for Caregivers in the Neonatal Intensive Care Unit 229Mark Rea

The primary aim of this article is to define good lighting for care-givers (both medical staff and families) working in the hospitalneonatal intensive care unit (NICU) and other areas associatedwith the critical care environment. Defining good lighting requiresunderstanding that lighting is not only important for the infants inthe NICU but that it also plays significant roles for adults in theNICU. First, lighting supports visual processes (eg, acuity, colorvision, visual performance). Second, lighting affects circadian regulation (eg, alertness, sleeping, hormone production). Finally,lighting communicates a message to professional staff as well asparents and visitors about the level of care and sophistication provided by the hospital. By thoughtfully addressing all threeroles, the lighted environment in the NICU can support the pro-ductivity and well-being of the professional staff, the health andsafety of patients, as well as the profitability of the NICU. A sec-ondary aim of this chapter is to provide practical guidance tohealth care professionals on how to articulate good lighting objec-tives to application engineers and designers responsible for thelighting in the NICU.

Effects of the Neonatal Intensive Care Unit on Auditory Attention and Distraction 243 Lincoln Gray and M. Kathleen Philbin

A theory is proposed that attention to acoustic signals is importantfor normal development and varies with background maskingsounds. Specifically, the theory states that distractibility increaseswith decreasing predictability of the acoustic environment andwith decreasing age. Literature from premature neonates, normalinfants, preadolescent children, children with attention deficit disorders, and adults is reviewed. One conclusion is that an envi-ronment perceived by adults as predictable may be distracting forpreterm infants. One recommendation for future research is toinclude measures of background acoustic predictability as inde-pendent variables or covariates in developmental studies.

Olfaction in the Fetal and Premature Infant: Functional Status and Clinical Implications 261Benoist Schaal, Thomas Hummel, and Robert Soussignan

This article considers olfaction as a functioning source of informationfor the fetus and the neonate, born on term or prematurely. It aimsto present how odors are involved in the sensory continuity

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between the prenatal and postnatal environments and how theyinfluence the earliest adaptive responses of newborns in the realmsof self-regulation, emotional balance, feeding, and social interac-tions. Finally, it evaluates odors as sensory means to ameliorate thephysiologic and behavioral responses of preterm infants to theadverse impacts of separation from mother, nonoral feeding, oriatrogenic distress.

Early Relationship Environments: Physiology of Skin-to-Skin Contact for Parents and Their Preterm Infants 287Joy V. Browne

Skin-to-skin care involves the mother placing her diaper-cladinfant upright between her breasts in direct skin contact. The practicehas evolved worldwide to be an intervention strategy in neonatalintensive care units for premature infants and their mothers. Fewadverse outcomes have been noted in thermoregulation, cardio-vascular changes, or behavioral organization. Findings have beenpositively related to better infant physiologic and neurobehavioraloutcomes, maternal breastfeeding success, and positive attachmentrelationships. The early, intimate, and physiologically stabilizingbenefits of skin-to-skin care provide for a new conceptualization ofthe optimal environment for preterm infants in intensive care.

Evidence-Based Design for Infants and Staff in the Neonatal Intensive Care Unit 299Mardelle McCuskey Shepley

Conscientious architects are becoming increasingly aware of theimpact of design decisions on the sensory environment of the neo-natal intensive care unit (NICU). This article addresses the relevanceof theories of environmental psychology to NICU design. Designresearch on infants and staff in NICUs is summarized, and futureresearch directions are identified.

Planning a Developmentally Appropriate Neonatal Intensive Care Unit 313Judy Smith, Kathleen Bajo, and Judy Hager

Neonatal intensive care units (NICUs) are now being redesigned inthe wake of growing evidence that the physical environment of theNICU has a profound impact on all who live and work there.These new units reflect the universal trend of bringing familiesdirectly into the center of the medical care team. More than ever,such projects are bound to change how staff care for babies, howfamilies interact with babies, how staff and families interact withone another, and how staff interact among themselves. When aNICU decides that a more developmentally appropriate environ-ment should be initiated, the question of funding and obtaining

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other resources inevitably arises. This chapter identifies the essentialcomponents that should be included when planning to seek invest-ments in NICU facilities.

Lighting Design in the Neonatal Intensive Care Unit: Practical Applications of Scientific Principles 323Robert D. White

Meeting the varied lighting needs of infants, caregivers, and familieshas become more complex as our understanding of visual develop-ment and perception and the effect of light on circadian rhythmsadvances. Optimal lighting strategies are discussed for new unitconstruction, as well as modifications to consider for existing units.In either case, the key concept is that lighting should be providedfor the individual needs of each person, rather than the full-roomlighting schemes previously used. Ideas gleaned from nonhospitalsettings, re-introduction of natural light into the neonatal intensivecare unit, and new devices such as light-emitting diodes will dramatically change the lighting and visual environment of futureneonatal intensive care units.

Planning the Acoustic Environment of a Neonatal Intensive Care Unit 331M. Kathleen Philbin

This article addresses general principles of designing a quietneonatal intensive care unit (NICU) and describes basic aspects ofroom acoustics as these apply to the NICU. Recommended acousti-cal criteria for walls, background noise, vibration, and reverberationare included as appendices. Crowding in open, multiple-bedNICUs is the major factor in designs that inevitably produce noisynurseries with limited space for parents. Quiet infant spaces withappropriate sound sources rely on isolation of the infant from facil-ity and operational noise sources (eg, adult workspaces, supplydelivery, and travel paths) and extended contact with family mem-bers. However, crowding has been an important influence on theclinical practice and social context of neonatology. It allows clini-cians to rely on wide visual and auditory access to many patientsfor monitoring their well-being. It also allows immediate socialcontact with other adults, both staff and families. Giving up thiswide access and relying on other forms of communication in orderto provide for increased quiet and privacy for staff, infants, andparents is a challenge for some design teams. Studies of the effectsof various nursery designs on infants, parents, clinicians, and thedelivery of services are proposed as a means of advancing the fieldof design.

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Designing the Neonatal Intensive Care Unit for Optimal Family Involvement 353Beverley H. Johnson, Marie R. Abraham, and Rosalie N. Parrish

The design of a new neonatal intensive care unit provides anopportunity to ensure that the new facility best meets the needs ofthe infants and families whom the unit serves. In design planning,administrators, staff, family members, and the architect must worktogether in a self-education process that entails examining currentdesign standards, exploring exemplary facilities at other institu-tions, defining the priorities and needs of infants, families, andstaff, and deciding how to respond to them. The involvement offamily members in this important work can help ensure that thefacility is responsive to families and supports the family as theprimary caregiver and decision maker for the infant. Such an envi-ronment will lead to improved health and developmental outcomesfor infants and greater family and staff satisfaction.

Mothers’ Arms—the Past and Future Locus of Neonatal Care? 383Robert D. White

With the advent of neonatal intensive care, medical professionalsinserted themselves between the baby and its family. Even forhealthy newborn, the mother could only get to her infant with per-mission from the medical staff and then only for limited periodsand in a very restricted manner. Family-centered care restored thefamily’s right to full access to their baby, but as generally practiced(and certainly as NICUs are currently designed) medical profes-sionals still view the infant as a solitary individual who sleepsmost of the time in a bed. Future NICU design should recognizethat the baby must spend most of its time in its mother’s arms toget the full benefit of her sensory environment as experiencedthroughout our evolution. NICUs must therefore be planned tofacilitate this extended proximity as much as possible (ie, not justproviding for parents at the bedside with the bed as the locus ofcare, but transforming the preferred and predominant locus of carefrom the bed to the parents’ arms, with the design changes inherentto that concept). Designing our units to facilitate this interactionwill not assure that it will always occur, but it will guarantee thatwe have not created permanent structural features that interferewith this crucial relationship.

Index 389

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