Guest Editorial
Article Outline
The design and operation of newborn intensive care units (NICUs) have evolved over the period of 1960s to 1990s to support and accommodate the changes in technology involved in meeting the physiological, nutritional, and treatment needs of preterm and high-risk infants. The equipment and care practices changed, the space enlarged, and the units cared for many more infants. The units were designed as large, open areas with easy visibility for the caregivers. The infants were in rows, close to each other with open space between bays. The technology advanced with the ability to keep smaller and smaller infants alive. Small infants, less than 1500 g, began to occupy most patient days with many stays of 3 months or longer. Although the survival rate improved, the number of infants with evidence of neurological and learning problems increased.
The focus on the environment of the fetus, preterm infant, and young neonates began in the 1970s but made little progress in changing the environment of the fetus or infant until the 1980s and early 1990s.1, 2 Even in 2008, it is estimated that less than half of the more than 1000 NICUs in the United States and even fewer in Europe and Asia are able to maintain an environment and care practices that are supportive of early neurosensory and neuromotor brain development. These units support the physiology of care, but many fail to support the needs for healthy early brain development, both neurosensory and neuromotor.
This issue of NAINR has a major focus on the issues involved in early neurosensory development and the role of the environment in supporting or inhibiting brain development. The introduction and overview article focus on a series of basic principles, concepts, and processes that are essential for healthy neurosensory development. Although preterm birth accelerates the maturation of the lungs, kidneys, and gastrointestinal tract, it does not accelerate neuroprocesses, and under most conditions of care, it retards or seriously alters these processes. Those processes, which were under genetic direction or control, were believed to be important but not altered by the environment. With the studies of epigenetics, it is now clear that environmental factors can alter the expression of genes related to brain development without altering the DNA structure or code for the gene. The environmental epigenetic influences on gene expression affect not only the fetus or infant but also the eggs in the female fetus, thus affecting the succeeding generation. Mothers who were exposed to diethylstilbestrol (DES) saw the adverse effects in their daughters and granddaughters. Thus, the developmental environment takes on new meaning.
The sensory environment including noise, bright lights, sleep deprivation, and poorly timed caregiving all alter neurosensory development in the preterm infant. The physical environment, the nutritional environment, and the social/emotional environment also influence the processes involved in the early development of the neurosensory systems. The first article on sleep and brain development presents the science of sleep and the critical role it plays in early brain development. Many NICUs have no policies or clear procedures for supporting and protecting sleep and sleep cycles for infants.
The articles on visual development, chemosensory development, and auditory development all describe the basic processes involved in the development of each sensory system. These are the processes that are positively or negatively affected by the NICU environment and care practices.3
Developmentally appropriate care in an environment that supports early brain development is essential for optimal outcome and the best possible long-term development. It is essential that all NICUs make the changes needed to have an environment and care practices that support the processes of early brain development. For many infants, the critical periods in their brain development occur while they are in utero or in the NICU. The current environment in many NICUs significantly contributes to problems encountered in long-term outcome.
References
- . The University of Missouri infant development unit and program. Zero Three. 1983;12–13
- . Environment of newborn infants in special care units. In: Gottfried AW, Gaiter JL editor. Infant stress under intensive care: environmental neonatology. Baltimore: University Park Press; 1985;p. 23–54
- . The sensory environment of the NICU: scientific and design-related aspects. Clin Perinatol. 2004;31:1–393
PII: S1527-3369(08)00126-8
doi:10.1053/j.nainr.2008.10.002
© 2008 Published by Elsevier Inc.
