A Soothing NICU Environment Improves Babies' Outcomes

The neonatal intensive care unit (NICU) is a special place, typically in larger hospitals, for newborn babies who require intensive care. NICU staff includes highly trained doctors (neonatologists) and neonatal nurses, who specialize in the care of premature and sick newborns.

When NICUs were first created in the 1950s, the focus was on saving premature babies’ lives with medical technology. But over the next several decades, even as medical advances saved more lives at increasingly younger gestational ages, it became clear that long-term outcomes were dismal. Many babies failed to thrive, continuing to struggle with chronic medical issues, disabilities, and atypical development. Why would this be so? What critical ingredient was missing from the NICU?

To solve this mystery, researchers in the 1980s, led by Heidelise Als, Ph.D., started assessing premature babies and noticing their discomfort and distress. Als and others started to wonder: Premature babies are ideally suited for the relatively quiet, dark, and wet womb. When they are born early, their immature nervous systems are simply not equipped to be bombarded with bright lights, loud noises, rough textures, dry air, unnatural positioning, sudden handling, and painful medical treatments. In addition, when parents are confined to the sidelines, this further stresses babies by depriving them of their parents’ presence and nurturing care. Their research confirmed that, indeed, as Als explained, “Exchanging the womb for the harsh NICU environment at a time of rapid brain growth compromises the infant’s early development, which results in long-term physical and mental health problems and developmental disabilities.”

As a result of this insight, great advances have been made in the care of all NICU babies, largely by broadening the scope of care. Whereas the traditional NICU focused on medical technology and ensuring physiological survival, the modern NICU also structures the environment and provides medical care in ways that are neuroprotective, as in, protecting babies’ immature nervous systems, and ensuring optimal, holistic well-being, and development. And for babies, a critical ingredient of neuroprotective care is the responsive nurturing of their parents.

Engaging parents as their babies’ primary caregivers is a philosophy of care that precious little should get between parents and their newborns. When NICUs began admitting parents in the 1970s, this first step was a huge paradigm shift. Before that, NICUs routinely barred parents, who were viewed as interlopers, potential sources of infection, and unnecessary for the well-being of babies in critical condition. But because of the parent-infant research by John Bowlby and others, forward-thinking doctors saw the damage separation could do and the value of close contact between parents and their babies. And although the 1970s NICU was not a welcoming place for parents (or babies for that matter), over the past five decades, there has been a slow but huge shift in how we think about what babies need and the role of parents in the NICU.

To make the NICU more neuroprotective, change has occurred in three major areas: the NICU environment, NICU care, and parent involvement.

NICU Environment

Lights are turned down whenever possible, and otherwise, eyeshades are placed on babies. The beeps and blasts of monitors and ventilators are turned way down, and when a baby is sleeping, the incubator can be covered to mute sounds.

NICU Care

Medical professionals as well as parents can learn how to read the baby’s behavioral cues, looking for signs of distress and signs of calm to determine what the baby needs to feel comfortable and soothed. In addition:

• Research on infant pain and effective pain medication has significantly advanced the humane treatment of NICU babies.
• Nurses position babies in ways that promote calm and comfort, which improves physical and neurological development.
• Instead of receiving regularly scheduled care, babies are allowed to continue sleeping and reap those benefits.
• Similarly, babies benefit from being fed when they show signs of readiness, rather than being fed according to the clock.

Perhaps most significant of all, Kangaroo Care—placing a diapered baby skin-to-skin on the parent’s bare chest—has proven, over the past 40 years, to be an incredibly effective way to promote infant well-being. Notably, struggling newborns whose lives aren’t in imminent danger can stabilize faster when placed on their mother’s chest, than when admitted to the NICU.

Parent Involvement

At first, parents were considered visitors who had to follow visiting hours. Then they were allowed to come at all hours but were considered “in the way” if they asked questions or voiced concerns. Nowadays, the gold standard NICU considers parents to be their baby’s primary caregivers. Parents are also astute observers of their babies, some spending many hours daily at the bedside, attuning to their babies. Medical professionals have learned the value of listening to parents’ assessments and concerns, sometimes warding off serious complications by being proactive, based on what parents are telling them about their own babies.

Finally, Kangaroo Care is neuroprotective—indeed, neuroessential—and parents are the best ones to provide it. Skin-to-skin contact between a baby and parent evokes neuro behaviors that ensure the fulfillment of basic biological needs, including having a stable heart rate, breathing, being warm, breastfeeding, restful sleep, and being soothed—all of which are particularly important for a vulnerable newborn's health and development, and helps parents feel like a parent to their baby, in spite of being in the NICU.

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The best NICUs no longer expect babies to fit into the traditional technology-centered environment nor to adjust to medically focused NICU care. Ideally, the NICU environment is designed to be neuroprotective; NICU care supports the holistic development of each baby; parents are engaged as their baby’s primary caregivers. And there is mounting evidence of the benefits. Babies in these gold-standard NICUs tend to experience fewer medical complications, grow faster, and leave the NICU sooner. Best of all, they have better long-term outcomes, with fewer chronic medical and developmental issues.

Neuroprotective developmentally supportive care and parent involvement appear to be key NICU ingredients.