International Journal of Pediatric Otorhinolaryngology 73 (2009) 951953

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International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

Noise levels in neonatal intensive care unit and use of sound absorbing panel in the isolette
E. Altuncu a,*, I. Akman a,1, S. Kulekci b,2, F. Akdas b,3, H. Bilgen a,4, E. Ozek a,5
a b

Department of Pediatrics, Division of Neonatology Unit, Marmara University School of Medicine, Turkey Department of Audiology, Marmara University School of Medicine, Istanbul, Turkey

A R T I C L E I N F O

A B S T R A C T

Article history: Received 13 December 2008 Received in revised form 16 March 2009 Accepted 20 March 2009 Available online 29 April 2009 Keywords: Noise levels Sound absorbing panel Noise reduction

Objective: The purposes of this study were to measure the noise level of a busy neonatal intensive care unit (NICU) and to determine the effect of sound absorbing panel (SAP) on the level of noise inside the isolette. Methods: The sound pressure levels (SPL) of background noise, baby crying, alarms and closing of el&Kjaer Sound Level Meter. Readings were isolettes door/portholes were measured by a 2235-Bru repeated after applying SAP (3D pyramidal shaped open cell polyurethane foam) to the three lateral walls and ceiling of the isolette. Results: The median SPL of background noise inside the NICU was 56 dBA and it decreased to 47 dBA inside the isolette. The median SPL of monitor alarms and baby crying inside the isolette were not different than SPL measured under radiant warmer (p > 0.05). With SAP, the median SPL of temperature alarm inside the isolette decreased signicantly from 82 to 72 dBA, monitor alarm from 64 to 56 dBA, porthole closing from 81 to 74 dBA, and isolette door closing from 80 to 68 dBA (p < 0.01). There was a signicant reduction in the noise produced by baby crying when SAP was used in the isolette (79 dBA vs 69 dBA, respectively) (p < 0.0001). There was also signicant attenuation effect of panel on the environmental noise. Conclusions: The noise level in our NICU is signicantly above the universally recommended levels. Being inside the isolette protects infants from noise sources produced outside the isolette. However, very high noises are produced inside the isolette as well. Sound absorbing panel can be a simple solution and it attenuated the noise levels inside the isolette. 2009 Elsevier Ireland Ltd. All rights reserved.

1. Introduction The American Academy of Pediatrics (AAP) suggests that sound pressure levels (SPL) inside isolette should not exceed 45 dBA [1]. Infants in a busy neonatal intensive care unit (NICU) are frequently exposed to adverse environmental conditions like loud noise, bright light. In addition to clinical problems specic to prematurity like recurrent apnea and bradycardia, nutritional deciencies, these environmental conditions may act in combination to impact

* Corresponding author at: Barbaros Mah., Tophanelioglu Cad. Petek Sitesi No. 70, sku dar, Istanbul, Turkey. Tel.: +90 0216 327 10 Blok D 8, 34662 Altunizade U 10x411; fax: +90 0216 373 69 44. E-mail address: emelkayrak@yahoo.com (E. Altuncu). 1 Acar Kent, C 397, C2 Kaps Yan, Beykoz, Istanbul, Turkey. 2 y, Istanbul, Turkey. Tekin sk., Besen Sitesi B Blok D 7, 34718 Acbadem, Kadko 3 kova Apt. No. 27/8, 34738 Erenko y, Istanbul, Turkey. Ethem Efendi Cad. Go 4 Istanbul Evleri C2/17, 34077 Kemerburgaz, Istanbul, Turkey. 5 Marmara Universitesi Hastanesi, Pediatri Ana Bilim Dal, Barbaros Mah., sku dar, Istanbul, Turkey. Tophanelioglu Cad. No. 13/15, 34662 Altunizade, U 0165-5876/$ see front matter 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2009.03.013

on the developing brain [2]. In the neonate, loud noise has been associated with hypoxemia and altered behavioral responses or cardiovascular symptoms (tachycardia and hypertension) [35]. Noise also can have severe consequences for the newborns in the long terms, in terms of interfering with their psycho-biological balance resulting in the disruption of the normal growth and development. Additionally, it can cause sleep disorders and interfere with circadian rhythms [1,3,6]. Loud and prolonged sounds can produce hearing loss in the frequency range of the damaging sounds [7,8]. The aims of this study were to measure the noise level of our NICU and to compare the levels of noise produced by the other sources inside or outside of the isolette. We also aimed to investigate if a sound absorbing panel (SAP) would reduce the noise inside the isolette. 2. Methods In this study, all environmental noise level measurements were done on the same day during morning shift in the NICU. The

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E. Altuncu et al. / International Journal of Pediatric Otorhinolaryngology 73 (2009) 951953 Table 1 Noise levels under radiant warmer and inside the isolette. Measurement conditions Noise level (dBA) Radiant warmer Median (2575 IQR) Background noise Monitor alarm Baby crying p < 0.05 is signicant. 56 (5361) 64 (6366) 75 (7476) Isolette Median (2575 IQR) 47 (4549) 64 (6465) 79 (7481) <0.0001 0.893 0.051 p

el&Kjaer) Sound Level equipment used was a 2235-B&K (Bru Meter (SLM). The meter was set to record A weighted slow response integrated sound levels (dBA), which represents the acuity of the human ear for various frequencies [9]. The measurements in the isolette (AirShields C450) were done placing the microphone of the SLM a few centimeters from a place presumably where the infants head was. During all measurements, there were no babies in the isolette or under radiant warmer. Sequential measurements were performed for every 15 s over a 5 min observation period for each category. The measured SPL of noise parameters were as follows; (1) background noise, (2) prerecorded sound of baby crying, (3) alarms and (4) closing noise of isolettes door/portholes. All sound measurements were recorded concurrently with care giving activities and events. Background noise level of unit was measured while ve patients were being monitored, of which two were mechanically ventilating. All the measurements were completed within 60 min and during this time we controlled all the noise producing activities in the nursery such as the telephone was disconnected, nobody was allowed to visit the nursery except the two doctors and one nurse who were working in the shift. Basal sound level of the isolette was measured while engine was switched on. To measure the noise of crying, a term baby cry was rst recorded during phlebotomy with a Vestel CD-92WO tape recorder. This prerecorded sound was used in all measurements at the same voice level of the tape recorder. The noises of closing the isolettes door/portholes were measured separately. While measuring the noise produced during the closure of portholes, we structured the procedure as following: we opened the porthole, waited for 5 s and then closed it. After waiting for another 5 s, we repeated the procedure. Measurements of each category were repeated after applying sound absorbing panel (3D pyramidal shaped open cell polyurethane foam) with absorptive surface to the three lateral walls and ceiling of the isolette (Fig. 1). The maximum thickness of SAP was 6 cm; the minimum thickness was 2 cm. We used SPSS (Statistical Social Sciences; SPSS, Inc., Chicago, IL) for the statistical analysis. The data were expressed as median (25 75 interquartile range (IQR)). MannWhitney U test was used for the analysis of differences. Statistical signicance was accepted as p < 0.05.

Table 2 Noise levels inside the isolette with or without sound absorbing panel. Measurement conditions Noise level (dBA) Isolette Median (2575 IQR) Background noise Monitor alarm Temperature alarm Baby crying Porthole closing Isolette door closing Engine OFF alarm
a

p Isolette with SAPa Median (2575 IQR) 43 56 77 69 74 68 63 (4146) (5457) (7678) (6573) (6379) (6179) (6164) 0.004 <0.0001 <0.0001 <0.0001 0.005 0.015 <0.0001

47 64 82 79 81 80 67

(4549) (6465) (8083) (7481) (7388) (6987) (6768)

SAP: sound absorbing panel.

3. Results The median background noise was 56 (5361) dBA under the radiant warmer (in a free eld) and it decreased to 47 (4549) dBA inside the isolette (p < 0.0001) (Table 1). The median sound levels of monitor alarm were not different inside the isolette (64 dBA) and the radiant warmer (64 dBA) (p > 0.89). The maximum levels were recorded during crying of a baby and it was extremely high at a median level of 75 dBA under radiant warmer and 79 dBA inside the isolette (p = 0.051). The median background noise in the NICUs was 43 dBA inside the isolette with SAP and there was signicant attenuation effect of the panel on the environmental noise (p = 0.004). Panel also attenuated the noise produced by the other sources inside or outside of the isolette (Table 2). With panel, the median level of temperature alarm noise inside the isolette decreased signicantly from 82 to 77 dBA (p = 0.0001), monitor alarm from 64 to 56 dBA (p = 0.0001) and engine off alarm from 67 to 63 dBA (p = 0.0001). Closing portholes or door of the isolette produced noise with a median of approximately 80 dBA, and panel blunted these kinds of brief amplied noises. The median noise levels of porthole and isolette door closing were 74 and 68 dBA in the isolette with SAP, respectively (p = 0.005 vs p = 0.015). There was a signicant reduction in the noise produced by baby crying when SAP was used in the isolette (79 vs 69 dBA, p < 0.0001). 4. Discussion Over the last 40 years with the new instruments, the NICU has become a very noisy place. The research of Thomas reports the sound level measurements ranging from 58 to 117 dBA in the patient care environment of a Level III NICU [10]. Our study showed that nearly all sound levels recorded during our study signicantly exceeded the limits of 45 dBA recommended by the AAP [1]. We found a background noise of 56 dBA under the radiant warmer and it decreased to 47 dBA inside the isolette. It seems that being inside the isolette protects infants from the background noise, but does not protect from the other noise sources. The level of monitor alarm was same both inside and outside of the isolette,

Fig. 1. Sound absorbing panel (3D pyramidal shaped open cell polyurethane foam) to the three walls and ceiling of the isolette.

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but although it did not reach a statistical signicance, babys cry had a stronger noise level inside the isolette. Similar ndings were reported by Bellieni et al. and they showed that the background noise ranged from 4650 dBA, closing portholes ranged from 70 74 dBA, baby cry from 8187 in the isolette [11]. A noise source operating inside the isolette produces a reverberating sound eld. Sound waves impinge on all the surfaces of the isolette before returning to the infants ears from many points [5,12]. This study demonstrates that, SAP reduced the noise levels due to crying, closing portholes and alarms as well as the background noise level. Amplication of the sound with the isolette walls was reduced by SAP, so the noise decreased dramatically. This nding is consistent with the researches reported in the literature in that foam lessens noise reection and reverberation by absorbing sound in the isolette [5,11,12]. As an increase of 3 dBA represents a doubling of sound pressure, a corresponding decrease represents halving of sound pressure. In the study of Bellieni et al., noise level of closing portholes decreased from 7374 to 7071 dBA, temperature alarm from 56 57 to 5051 dBA and baby cry from 8487 to 8285 dBA in the isolette with SAP, but the background noise did not change [11]. Noise especially when it is sudden and loud causes excitation of the subcortical systems and the hormone regulatory system (catecholamine and corticosteroid secretion) [6,13]. Failure to maintain noise level under the recommended levels may result in numerous adverse noise-induced health effects like hearing loss, abnormal development of sound frequency discrimination, tachycardia, tachypnea, apnea, hypoxia, abnormal sleep pattern, abnormal emotional development on newborn babies [1,5]. Many studies examined the effects of the noise reduction and many suggested strategies to reduce the noise. Simple strategies to reduce the noise like no tapping or writing on the tops of isolette and hoods, careful closing of isolette doors, soft shoes, encouraging staff to answer alarms quickly, asking staffs to speak softly, restricting teaching rounds at the bedside, restricting visitors, covering the isolette are the rst steps [10,12,14]. If such simple, inexpensive strategies fail to reduce the noise level to safe levels, more technical strategies need to be considered. One option is to use the various kinds of sound absorbing materials. They were used on available surfaces such as oors, walls and ceilings of the NICUs. There are three basic options for ooring in the NICU-sheet vinyl, carpets, and rubber ooring. Acoustical ceiling tiles are particularly important to consider if the heating/air conditioning systems is noisy [15]. Sound absorbing panels do not affect direct sound but trap and dissipate reected sound [11,15]. This then reduces the noise levels. If there is no opportunity to remodeling or renovation of NICU and nursery cannot be modied for more quiet condition, simple acoustical foam application inside the isolette can be a feasible solution to reduce noise. Except a few studies examining the SAP application inside the isolette, there has been no

documented data on the routine use of SAP in the isolette in the literature [5,11]. Noise control in the NICU would promote sleep, support physiologic stability and reduce potential adverse effects on auditory development of premature infants. In conclusion, the noise level is above the recommended levels in our NICUs as way of Level III NICUs. Strategies should be extended to reduce the chronic noise during lengthy hospital stays and this may affect some morbidity in preterm babies. Changing care giving behaviors is always the initial step in the reduction of noise level, but it is important to consider other individualized options like using SAP for controlling and reducing noise level. SAP can be a simple solution and it decreases the pressure of sound dramatically. Disposable property of SAP in the issues of hygiene adds an advantage to its practical utility in the NICUs. Further investigations into the possible role of SAP in the reduction of noise and impact of the long-term morbidities, particularly in the neonates treated for long periods of time in the NICU, seem warranted and careful consideration must be taken in making recommendations for the clinical practice. References
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