The Full-Term and
Premature Newborn
& & & & & & & & & &
Sound and the Developing Infant in the NICU: Conclusions and
Recommendations for Care
Stanley N. Graven, MD
OBJECTIVE:
To present the conclusions and associated recommendations for care
developed by the Physical and Developmental Environment of the High -
Risk Infant Center, Study Group on Neonatal Intensive Care Unit ( NICU )
Sound, and the Expert Review Panel.
STUDY DESIGN:
A multidisciplinary group of clinicians and researchers reviewed the
literature regarding the effect of sound on the fetus, newborn, and preterm
infant and developed recommendations based on the best evidence. An
Expert Review Panel reviewed the data and conclusions.
RESULTS:
The following recommendations are developed from the review of the
literature and are clarified in the body of the article. ( 1 ) Women should
avoid prolonged exposure to low - frequency sound levels ( < 250 Hz )
above 65 dB ( A ) during pregnancy. ( 2 ) Earphones or other devices for
sound production should not be used directly attached to the pregnant
woman's abdomen. ( 3 ) The voice of the mother during normal daily
activities, along with the sounds produced by her body and those present in
her usual surroundings, is sufficient for normal fetal auditory development.
The fetus does not require supplemental stimulation. Programs to
supplement the fetal auditory experience cannot be recommended. ( 4 )
Infant intensive care units should incorporate a system of regular noise
assessment. ( 5 ) Sound limit recommendations are to maintain a nursery
with an hourly L eq of 50 dB ( A ) , an hourly L 10 of 55 dB ( A ) and a 1 -
second L max of 70 dB ( A ) , all A - weighted, slow response scale. ( 6 ) Infant
intensive care units should develop and maintain a program of noise
control and abatement in order to operate within the recommended
permissible noise criteria. ( 7 ) Care practices must provide ample
opportunity for the infant to hear parent voices live in interaction between
parent and infant at the bedside. ( 8 ) Earphones and other devices
attached to the infant's ears for sound transmission should not be used at
any time. ( 9 ) There is little evidence to support the use of recorded music
Departments of Community and Family Health, Pediatrics, and Psychiatry (S.N.G.), University
of South Florida, Tampa, FL.
Address correspondence to Stanley N. Graven, MD, Department of Community and Family
Health, College of Public Health, University of South Florida, 13201 Bruce B. Downs Boulevard,
Tampa, FL 33612.
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& & & &
or speech in the environment of the high - risk infant. Audio recordings
should not be used routinely or left unattended in the environment of the
high - risk infant.
CONCLUSION:
The recommendations, if followed, should provide an environment that will
protect sleep, support stable vital signs, improve speech intelligibility for the
infant, and reduce potential adverse effects on auditory development.
Journal of Perinatology 2000; 20:S88 ± S93.
INTRODUCTION
The Study Group on Neonatal Intensive Care Unit (NICU) Sound
and the Expert Panel convened by the Center for the Physical and
Developmental Environment of the High-Risk Infant have reviewed
research and published data from more than 4000 references related
to human and animal auditory development and the effects of
environmental sound and noise exposure at different levels of fetal or
neonatal maturity. These studies have been presented in the articles
of this special supplement to the Journal of Perinatology. From
these articles, original research data, and other references, a series of
conclusions has been formulated that forms the basis for the specific
recommendations presented. Recommendations are limited to those
supported from credible research studies.
Many reports of uncontrolled studies, limited observations, case
reports, and personal experience have been used to create and
implement various care or intervention practices in the NICU. Special
equipment has even been designed to deliver auditory stimulation in
various forms, and in some cases has been widely marketed. Given
the absence of randomized controlled trials, it is not possible to
recommend any of the currently marketed intervention programs.
Recommendations and conclusions are organized and presented
here to enable physicians, nurses, other professionals, and parents to
develop programs for controlling noise in the NICU and enhancing
auditory development in preterm as well as term infants. The
recommendations can be carried out without new technology and
usually with limited changes in the NICU physical arrangements.
Implementation of the recommendations will, however, require
major changes in the culture of many NICUs and widespread
support among members of the NICU team. It is extremely
important that the leadership and staff of the NICU become
Journal of Perinatology 2000; 20:S88 ± S93
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www.nature.com/jp
Sound and the Developing Infant in the NICU
knowledgeable about auditory development in the fetus and preterm
infant and about adverse effects of noise. It is also important to
understand the role of the human voice and speech in early infant
auditory neurosensory development.
The conclusions and recommendations for care that follow are
based on research published through 1999 and are presented as an
effort to link research, both animal and human, to care practices.
The purpose is to provide clinicians with a consistent, defendable set
of practice guidelines. These conclusions and recommendations are
by no means final, but represent a stage in a process to adapt the
environment and care practices so that they support and enhance the
neurosensory development of the preterm and high-risk newborn.
These recommendations will require updates and modification as
new data become available.
CONCLUSIONS
The review articles published in the Journal of Perinatology were
prepared and organized to provide the reader with a summary of
current research in a form that could be used by physicians,
nurses, and other professionals working in NICUs. The following
conclusions are based on data cited in the preceding articles and
references.
(1) The auditory system of the human fetus is sufficiently
mature for sound to produce physiologic effects as early as 23 to 25
weeks of gestation.1 ± 3 (See Hall in this supplement, page 12).
External vibroacoustic stimulation or exposure to intense external
low-frequency noise can increase glucose consumption and
presumably increase oxygen consumption, fetal heart rate, and fetal
movement.3 ± 7 (See Abrams et al., page 31 and Gerhardt et al., page
21 in this supplement) Vibroacoustic stimulation or any other
auditory source applied directly to the skin of the abdomen over the
uterus will be little attenuated and can be amplified into the
threshold range for pain in adults. Such stimulation can cause
changes in fetal state, activity, and physiology.1,6
(2) In the human uterus, the background noise level is over 50
dB at the lower frequencies ( <250 Hz) with short bursts over 70
dB.5 ± 7 Lower-frequency ambient sounds from the external maternal
environment also contribute to the in utero background noise level.
However, lower frequencies of the maternal voice are heard well and
discriminated above the in utero background noise.6 Sounds at <250
Hz reach the fetus through the tissues surrounding the uterus with
little attenuation.6 Attenuation is significant at frequencies above 250
Hz. After birth, the infant will recognize the mother's voice filtered for
frequencies >250 Hz (as heard in utero) and distinguish it as
different from the unfiltered mother's voice with all frequencies
included.8 ± 10
(3) Prior to birth, the human fetus has the capacity for voice
discrimination and auditory memory involving speech and musical
sounds with frequencies <250 Hz. The gestational age for the onset
of this capacity is not established but has been demonstrated to be
present prior by 35 weeks of gestation.11 ± 13 (See Moon et al., page 37,
Journal of Perinatology 2000; 20:S88 ± S93
Graven
in this supplement). The fetus at 35 weeks is able to discriminate
among different phonemes.12 The timing of auditory maturation is
not altered by preterm birth.
(4) Prenatal exposure of the human fetus to maternal speech is
believed to be a factor in subsequent speech and language
development.8 ± 13 The long-term effects of missed exposure to
maternal speech in late fetal life are not known.11 ± 13
(5) In all animals studied to date, neurosensory development
follows a sequential pattern.14 (See Lickliter, page 45, in this
supplement). It is assumed that human neurosensory development
follows the same sequence. Sensory development begins with
sensations particular to skin (touch) followed by kinesthetic
(movement), chemosensory, auditory, and finally visual develop-
ment. Preterm birth does not alter the sequence. Stimulation of a
particular sensory system at a given time in fetal or early neonatal
development can facilitate or be essential for normal development of
that sensory system. The same stimulus, if too intense or atypically
timed, can interfere with normal development processes in that system
as well as other sensory systems. This phenomenon has been observed
in a number of animal species. For example, early introduction of
light or unusual vestibular stimulation can alter auditory
development. Because of strong linkages between the developing
sensory systems, the amount, type, and timing of sensory stimulation
or experience are important to prenatal and postnatal neurosensory
development. The effect of stimulation of a single sensory system
cannot be studied in isolation because the effects of stimulation or
experience of one system will influence other sensory systems as well.14
(6) In utero exposure of the animal fetus to intense low-
frequency sound can damage or destroy hair cells of the developing
cochlea as well as auditory nerve connections during vulnerable
periods of late fetal life.3 ± 7,15,16 In these animals, the effects of low-
frequency sound exposure vary depending on the maturity of the
fetus at the time of exposure, the intensity of the sound, and
duration.
Increased rates of hearing loss were reported in school age
children whose mothers were exposed to noise levels of 65 to 85
dB(A) in work environments 8 hr/d during pregnancy.17,18 There
have been no subsequent studies reported. There is no evidence that
external ambient sounds, which are comfortable for the mother
without hearing protection, result in auditory injury to the fetus. This
does not apply to the direct application of sound sources, i.e., head
phones, to the mother's abdomen.
While fetal sensory deprivation can be experimentally produced in
animals, similar situations in humans are not described. There are
isolated examples of human pregnancies in which there is very
limited auditory stimulation (e.g., mothers who are mute). The
short- or long-term effects on fetal auditory development under
these conditions have not been reported.
(7) Sound will produce physiologic effects by 23 to 25 weeks of
gestation in the preterm infant.1,2,16 Sudden intense bursts of sound
>70 dB can cause a series of physiologic responses that includes
changes in heart rate, blood pressure, oxygenation, respiration,
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 Graven
intestinal peristalsis, and glucose consumption. Noise control may
contribute to physiologic stability during critical care (Graven SN,
unpublished data).
(8) The auditory system of the preterm infant is sufficiently
mature by 30 to 32 weeks to permit auditory learning. Auditory
learning has been demonstrated at 35 to 36 weeks. This occurs with
naturally occurring stimulation and does not require programming.
The precise age at which it begins is not established.1 ± 4,11 ± 13 The
human infant at term is able to recognize and discriminate the
mother's voice.12,19 ± 27 This ability assists the newborn in orienting to
the mother's voice and probably plays a role in the infant±mother
attachment processes.
(9) The auditory system of the infant in the NICU is not shielded
by the maternal tissues which significantly attenuate frequencies
>250 Hz. Thus, the infant is exposed to more high-frequency
sounds than would have been experienced in utero. The sound
environment of the NICU often has high levels of both low- and
high-frequency sound. Therefore, the infant's exposure to ambient
noise, as well as to the human voice. is significantly different from
the in utero experience 3,27 ± 29 (Graven SN, unpublished data).
(10) The periods in prenatal life when the animal fetus is
vulnerable to cochlear damage from intense low-frequency sound
would be applicable to the human preterm infant as well.6,7,15,16 The
risk of cochlear injury from low-frequency sound is related to
maturity of the infant, intensity of the low-frequency sound, and
duration. In utero, the fetus is protected from the effects of high-
frequency sound through attenuation provided by tissue absorption
of high-frequency sound. The preterm infant in the NICU does not
have this protection from high-frequency sound. There are no data
on long-term effects of high-frequency sound exposure to infants in
the NICU.
(11) Continuous sound or noise exposure at 60 dB and above
has been associated with potentiation of the effect of ototoxic
agents.30,31
(12) Noise exposure at or above 60 dB has been associated with
consistent sleep disturbance.28,32 ± 37
(13) Specific hearing loss, as measured by pure tone audiometry
and attributable to noise levels alone, has not been reported in
human infants.38 ± 42 Animals, including humans, can sustain
significant permanent changes in auditory sensitivity associated with
loss of substantial numbers of sensory cells and have no measurable
losses detected by pure tone audiometry.37,38 ``Normal auditory
sensitivity for pure tones is not indicative of an injury-free organ of
Corti nor a completely intact auditory nerve.''39
(14) Many long-term follow-up studies of preterm infants find
increased frequencies of speech delay, language-related problems,
and a wide range of learning problems that may be related to
auditory function.43,52 School age children who were preterm births
had alterations in both topographic location and volume of the
auditory cortex when compared to term infants assessed by
functional MRI (Ment, L, unpublished data). The exact relationship
of the long-term problems to specific events of preterm birth and
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Sound and the Developing Infant in the NICU
NICU care has not been established, but justifies concern for the
effects of high noise levels.
(15) It is possible to determine noise levels in a NICU using
existing technology.53 The instruments and methodology are easily
accessible.
(16) NICU sounds comprise a wide range of frequencies. Some
NICU sounds are continuous and many others are episodic (e.g.,
alarms). The sources of sound are exceedingly varied depending on
the unit and activities. Excess sound production and reverberant
spaces are the primary problems in the NICU. Sound absorption will
not solve the problems of excess sound production that occurs. Most
sources of sound that keep the basic sound level over 55 dB(A) can
be modified or eliminated if carefully planned and carried out.
Operating a NICU at sound levels below 50 dB(A) requires the
cooperation of all people working in the unit.43 It also requires
attention to design and construction.54,55
RECOMMENDATIONS FOR PROTECTION OF THE FETUS
AND CARE IN THE NICU
(1) Women should avoid exposure to prolonged low-frequency
sound levels above 65 dB(A) during pregnancy.
Rationale: Sheep fetuses sustained injury to the hair cells of the
cochlea when exposed to sustained periods of intense low-frequency
sound.5 ± 7 The level of sound experienced by the sheep fetus was
comparable to what a pregnant woman could experience from
environmental exposure. In animals, the effect of low-frequency
sound exposure depended on the maturity of the fetus.3
Increased rates of hearing loss have been reported in school age
children whose mothers were exposed to noise levels of 65 to 85
dB(A) in work environments 8 hr/d during pregnancy.17,18 Maternal
tissues absorb and filter most high-frequency sounds.
(2) The attachment of earphones or other sources of sound
generation directly to the maternal abdomen over the uterus for
purpose of producing fetal auditory stimulation should be avoided.
There is no clear evidence of benefit and significant potential for
adverse effects. If vibroacoustic stimulation is used to assess fetal well
being, the instruments need to generate under 85 dB and be used
with caution until the human risk can be assessed.
Rationale: The sound intensity at the level of the fetal cochlea
from sound sources attached directly to the abdomen cannot be
predicted or easily assessed. Since they can easily exceed 85 dB(A),
they should be avoided.
(3) The human fetus should be exposed to the mother's voice
during the last 6 to 8 weeks of a term pregnancy. This occurs from
exposure to the mother's voice during the ordinary activities of daily
living and does not require any program to supplement or augment
the exposure. Programs to supplement or augment the in utero
auditory experience are not recommended until the benefits can be
demonstrated and risk of adverse effects can be carefully assessed.
Rationale: It is clearly established that the human infant at term
is able to recognize and discriminate the mother's voice.11 ± 13,18 ± 26 This
Journal of Perinatology 2000; 20:S88 ± S93
Sound and the Developing Infant in the NICU
has value for the newborn in orienting to the mother's voice and in
the infant±mother attachment processes. Some aspects of this fetal
auditory learning are present by 35 to 36 weeks of gestation 12,13,21 ± 24
and probably earlier.
There are many reports of programs and activities that use
recordings to provide specific speech or music stimulation to the
fetus. However, there are no controlled studies that demonstrate a
clear benefit nor are there any study to establish safety or assess the
risk of adverse effects.
(4) Infant intensive care units require a system of noise
assessment in order to meet recommended limits of sound
exposure for preterm as well as term infants. The system must
provide for assessment and recording of the hourly L eq, the hourly
L 10 and the 1-second L max.29 Hospitals need to provide a means
of addressing sound levels that exceed the permissible noise
criteria.
Rationale: Technology is available to accurately measure and
record noise levels in the NICU. For NICUs to meet the recommended
limits for noise, it is essential that the appropriate equipment be
installed and noise levels monitored appropriately. Periodic sampling
of noise levels often fails to measure the true sound exposure.53,55
(5) Infant intensive care units should develop and maintain a
program of noise control and abatement in order to operate the
NICU within the noise level recommendations. Recommended
permissible noise criteria are as follows:
In infant intensive care units, ``patient bed areas and
spaces opening onto them shall be designed to produce
minimal ambient noise and to contain and absorb
much of the transient noise that arises within the
nursery. The overall, continuous sound in any bed
space or patient care area shall not exceed: (1) an
hourly L eq of 50 dB and (2) an hourly L 10 of 55 dB,
both A-weighted, slow response. The one-second
duration L max shall not exceed 70 dB, A-weighted,
slow response''.29,54
Rationale: ``These permissible noise criteria will protect sleep,
support stable vital signs, and improve speech intelligibility for many
infants most of the time.'' These recommendations were published in
the Journal of Perinatology in 1999.29
The exact relationships of the long-term problems to specific
events of preterm birth and NICU care have not been established, but
justify concern for the effects of high noise levels.
(6) Hospitals should seek out policies and practices that
support and facilitate family members' sustained presence in the
NICU and their participation in the infant's care. Ambient noise
levels in the NICU must be controlled to levels that permit the
infant to hear and discriminate the human voice. Additionally,
care practices in the NICU must be organized to permit ample
opportunity for the preterm infant to hear and respond to the
voices of family members.
Journal of Perinatology 2000; 20:S88 ± S93
Graven
Rationale: The preterm infant has the same need for exposure to
human voice as the fetus (noted in Recommendation 3). Auditory
learning is important for language acquisition and social
attachment processes 11 ± 13,18 ± 26 (Graven SN, unpublished data).
(7) Earphones and other devices that deliver noise or music
directly to the infant's ears should not be used under any
circumstances. The addition of recorded voice or music to the
environment of the preterm infant is widely practiced. Since there
are insufficient studies of the effect on neurosensory development
and possible adverse effects, they cannot be recommended. If they
are used, sound sources should be kept at reasonable distances
from the infant's ear, played for brief periods, and played at levels
below 55 dB(A) at the infant's ear.28 Recorded sound cannot
replace interactive experience with another human, preferably a
parent. They should never replace contingent human voice
exposure.
Rationale: Devices applied directly to the infant ear may deliver
sound at levels that can be harmful and are not easily monitored by
staff without special equipment. If the sound is from sources removed
from the infant's ears, the level can be monitored and kept below the
recommended sound limit.
SUMMARY
The abovecited conclusions from the work of the Study Group on
NICU Sound are presented to provide a basis for policies and practices
that support normal neurosensory development in the preterm as
well as term neonate.
The vast majority of NICUs in the United States operate in an
environment that includes excess noise for the well being of the
infant receiving care. The high-technology world is noisy. Changing
the environment and eliminating the excess noise require a major
cultural shift and involve time, patience, and team work. Solving the
problems of noise production and abatement requires changes in
knowledge, attitudes, behaviors, and performance. Attitudes and
related behaviors are the greatest obstacle to change and program
adoption.
The beliefs in many NICUs are that (1) noise and environmental
issues are an unavoidable accompaniment of high-technology
intensive care and (2) environmental issues are unimportant. Since
the data are now clearly on the side of the need for noise abatement,
it is now essential that noise abatement be included as evidence-
based care and incorporated into NICU operating procedures. The
evidence and recommendations have been available for over 25
years.56,57
There is a serious need for specific research that investigates
possible links between problems of children at school age and issues
of prematurity (e.g., early nutrition and environmental stimuli in
the NICU). Any of these factors may play a significant role in
altering the processes of normal neurosensory development. They
require complex studies that include controlled trials and long-term
follow-up. These will be the challenges of the coming decade.
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 Graven
If noise abatement and sound control are achieved within the
recommended levels, benefits could include some or all of the
following: (1) increased physiologic stability with fewer episodes of
physiologic instability of infants in the NICU; (2) better growth rates
for infants; (3) more consistent and age-appropriate neurosensory
maturation; (4) facilitated parent±infant attachment and
interaction; and (5) fewer long-term problems in areas of speech
and language.
As more NICUs achieve appropriate acoustic environments, it will
be possible to assess the actual frequency and magnitude of the
predicted benefits. The potential for future research as well as benefits
from the practice changes are the important opportunities. They need
to be pursued actively. There are no known or even proposed
potential adverse outcomes that would limit or inhibit the adoption
of noise control guidelines.
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