A Risk of Sensory Deprivation in the Neonatal Intensive Care Unit
Alan H. Jobe, MD, PhD
T
he neonatal intensive care unit (NICU) environment
has changed for the better from the 1970s and 1980s
when the NICU was congested, noisy, and brightly lit
24 hours a day—a frenetic environment no doubt. Current de-
signs for the NICU as recommended by the Consensus Com-
mittee on Recommended Design Standards for Advanced
Neonatal Care (2013) emphasize noise and light suppression
with space for extended, intimate parental contact, and for par-
ents to “room-in” with the infant.1 These designs provide more
humane and patient plus parent friendly care, but also greatly
increase the floor space and, inevitably, increase cost substan-
tially. The motivations for the design of the new NICU have
been guided by concepts of developmental-appropriate care
of very preterm infants to minimize stress and optimize neuro-
developmental outcomes.2 The elements of developmental
care focus on minimizing stimulation of the infant by limiting
noise, sound exposure, and sleep interruptions. In practice,
NICU care is anthropomorphized by the NICU staff to envi-
ronments the adult caretakers think will be optimal for the in-
fant—an intrauterine environment that is generally assumed to
be dark, quiet, and without stimulation of the fetus. This
perspective results in care strategies such as single rooms for
preterm infants that are very quiet, often have low light 24
hours a day, and with an additional blanket over the isolette
to further suppress sound and light exposure. Contact with
staff is minimized so as to not disturb the infant. Pineda
et al3 report that contrary to their hypothesis that single rooms
would promote neurodevelopment relative to the ward envi-
ronment, preterm infants cared for in a ward and evaluated
at term had more normal brain structures as assessed by mag-
netic resonance imaging and better cerebral maturation scores
as assessed by electroencephalography than infants cared for in
single rooms. Further, when these infants were assessed at 2
years of age, the ward infants had better language and motor
scores than the infants cared for in single rooms.
How is this outcome possible? Pineda et al hypothesize that
the single room, with continuous low light and low sound, and
with isolation from stimuli, may result in sensory deprivation
to the developing brain. This explanation is strengthened by
their demonstration that parental visits tended to be short
and infrequent for their parent population.4 In contrast to
this experience, Ortenstrand et al5 reported benefits of
family-centered care with single rooms in Scandinavia, but a
parent was required to be continually present 24 hours a day
to help care for the infant. Of note, although developmental
care may benefit infants,2 such benefits are not uniformly re-
ported.6 Rather than arguing the perceived benefits of the ele-
NICU Neonatal intensive care unit
ments of developmental care and single rooms in the NICU,
brief reviews of the biology of sound, light, and manual stim-
ulation of preterm infants may be more fruitful.
Sound Exposures in the NICU
There is extensive literature describing the excessive sound
exposures for infants in the NICU, with recommendations
from the American Academy of Pediatrics for limiting these
exposures.7 Modern isolettes and ventilators are more quiet
than in the past, but the amount of continuous white noise
can be substantial and a hazard.8 However, sound exposure
is critical for the development of normal speech. The fetal
environment is not quiet, although high frequency sounds
are filtered out. The human fetus can hear and respond to
sounds by 23-24 weeks, and the development of the auditory
cortex is critically dependent on the auditory environment
from early gestation.9 Deprivation of maternal sounds will
interfere with the development of the fetal auditory cortex
and interfere with speech and language acquisition. The
amount of speech-related brain activity after birth increases
with more fetal exposure to speech.10 Surprisingly, language
exposure in utero initiates the fetus to the phonic character-
istics of its native language.11 However, following very pre-
term birth, exposure to adult language—maternal or from
the NICU staff—was found to be a small percent of the sound
exposure.12 The appropriate emphasis on sound abatement
in the new or renovated NICU should be on background
noise, alarm noise, and other non-human noises that can
startle and disrupt sleep of the preterm.13 However, the focus
on noise abatement has morphed into a goal of silence in the
NICU with exclusion of staff talk and lively discussions on
work rounds. The result may be a severe limitation of the
exposure of the vulnerable developing auditory cortex to hu-
man voices and sounds that are necessary for language devel-
opment. This delay in language development for infants in
single rooms is just what was observed by the Pineda article.3
In contrast, the open ward better reflects the fetal environ-
ment with human sounds and activities.
Light Exposures in the NICU
Although the fetus is in a dark environment in utero, the
fetus has a circadian rhythm entrained by maternal
From the Division of Pulmonary Biology, Cincinnati Children’s Hospital Medical
Center, Cincinnati, OH
A.J. is an Associate Editor of The Journal of Pediatrics. The author declares no
conflicts of interest.
0022-3476/$ - see front matter. Copyright ª 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jpeds.2014.01.072
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THE JOURNAL OF PEDIATRICS  www.jpeds.com
hormones.14 The circadian regulator in the brain—the hy-
pothalamic superchiasmatic nuclei—of the very preterm
baboon equivalent to about 24-week preterm infants, re-
sponds to light with increased metabolism and gene expres-
sion.15 Preterm infants cared for in dimly lighted rooms or
day-night lighted rooms develop circadian sleep patterns
independent of cycled light.16,17 Nevertheless, development
of the visual system requires visual experiences.18 Sight
deprivation interrupts visual development, and environ-
mental enrichment fosters brain plasticity. The fetal mouse
eye responds to light with signaling via melanopsin in the
fetal retina to induce regression of the hyaloid vasculature
and stimulate retinal development by down-regulating
vascular endothelial growth factor.19 Surprisingly, there is
enough light in utero in the mouse to signal melanopsin.
This same opsin that is present prior to rod and cone devel-
opment can signal a light avoidance response in newborn
mice.20 Circadian rhythms regulate more than sleep cycles,
and there is minimal research to explore other potential ef-
fects of light on the preterm infant. Accepting that the fetus
has a circadian rhythm and the dark-exposed preterm infant
does not, the conservative approach to exposure of the pre-
term infant to light would be cycling of dim light sufficient
for care at night to brighter light during the day. The
covering of the isolettes with blankets continuously seems
to be questionable because visual development requires
light exposure. The biology suggests that judicious light
exposure is appropriate until more is known about the ef-
fects of light on the preterm infant.
Physical Stimulation in the NICU
Physical stimulation of preterm infants is limited in the
NICU today by confining the infants in positional molds
and wrapping. But the fetus is intermittently active and
responsive to sound stimuli with brisk movements. Much
of fetal movement presumably is spontaneous, and the
handling of the newborn may be a different stimulus. At
the extreme, decreased fetal movements cause muscle con-
tractions. Most caregivers support kangaroo care as of benefit
to preterm infants and the parents. Kangaroo care includes
substantial tactile stimulation and increased sound and light
exposure relative to the isolette. Another form of stimulation
is passive physical activity and massage provided by the staff.
Moyer-Mileur et al reported in 1995 and again in 2000 that
daily physical activity increased bone mineralization and
growth in preterm infants.21,22 The loss of bone mineraliza-
tion in the preterm infant relative to the fetus at equivalent
gestational age results in part from the limited ability of cli-
nicians to supply adequate calcium and phosphorus. But
environment also matters, and a simple physical therapy pro-
gram can reduce bone reabsorption and promote bone for-
mation.23,24 This physical stimulus might be further
augmented with the human voice and a bit of light. Brain
plasticity can be optimized by multiple stimuli, and promo-
tion of that plasticity is essential for optimum normal devel-
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Vol. 164, No. 6
opment or to improve outcomes of preterm infants with
injured brains.18
Discussion
The report by Pineda et al demonstrates adverse neurodeve-
lopmental effects of single room neonatal care and should
sound an alarm.3 The study is imperfect in that infants
were not randomized to care environments. However, the
prospective and extensive assessments have yielded results
that seem to be more compelling for risk than some of the
benefits attributed to developmental care.6 My perspective
is that it is time for the neonatal community to stop designing
neonatal care based on what we think these infants would like
(anthropomorphosis) but rather on the biology of what stim-
uli will optimize neurodevelopment. The preterm newborn is
not equivalent to the fetus in metabolic, hormonal, or envi-
ronmental needs. The biology tells us that neurosensory
deprivation clearly is harmful, and is a possible consequence
of the single room environment. Stimuli for the preterm
seem to be conflated with stress, and too much minimization
of stimuli may impair development. However, the converse is
also likely true: too much stress will have adverse effects on
development. We do not know how much or what type of
sound, how much light, or how much physical stimulation
in combination will optimize brain development and plas-
ticity at which gestational ages. Parental participation in
the care of preterm infants is desirable, as is the suppression
of white noise and bright lights. We should use our resources
to get answers about how to best optimize brain plasticity for
the benefit of our patients. n
Submitted for publication Nov 6, 2013; last revision received Dec 18, 2013;
accepted Jan 30, 2014.
Reprint requests: Alan H. Jobe, MD, PhD, Division of Pulmonary Biology,
Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati,
OH 45229. E-mail: alan.jobe@cchmc.org
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