The Effects of Incubators on the Preterm Infant: History
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Alexia Séassau
,
Isabelle Carchon

Neonatal Intensive Care Units (NICUs) for very preterm infant do not provide the same living and development conditions as the intrauterine environment. Fetal sensory experience prepares the organism to interact with the sensory environment after birth. Early mature vestibular and tactile receptors are understimulated during an incubator stay, with isolation and reduced wear time outside of skin-to-skin. The incubator stay combines sensory deprivation, over-stimulation, and/or harmful, uncomfortable, or inappropriate stimulation with direct consequences on the brain maturation of the preterm newborn. 

  • prematurity
  • incubator
  • Neonatal Intensive Care Units

1. Introduction

Each year, it is estimated that 1 in 10 births worldwide, or 15 million children, are born prematurely [1]. Medical progress in perinatal care since the year 2000 has allowed the survival of these increasingly immature preterm children with low birth weights, resulting in an increasingly long hospitalization period [2].
Children born prematurely have sensory and perceptual peculiarities, with atypicalities depending on their experience in utero, their age, their birth weight, and the number of days spent in the neonatology department [3]. These atypicalities in processing information from the external environment alter their sensory-motor exploration abilities [4][5]. A higher prevalence of neurodevelopmental deficits exists in these preterm infants compared to full-term newborns, notably concerning intellectual and executive functions, attention, language, and social cognition [5][6][7][8]. The consequences of prematurity are therefore becoming a real public health issue [9].
Early interventions in Neonatal Intensive Care Units (NICUs) seek to limit deviant developmental trajectories. Since the 1980s, the introduction of early, individualized developmental care has shifted the focus from child survival to supporting the well-being of the child and the parents. In the incubator, the preterm newborn is exposed to inappropriate stimulation while in a critical period of physiological immaturity and cerebral development associated with atypical sensoriality. The technical environment of the NICU and the developmental fragility of preterm infant lead to disturbed parent–child interactions [10]. Consequently, the study of parent–child interactions is supported and included in the care process of these prematurely born children [11][12].

2. The Sensory Environment of NICU Incubators and Its Consequences on the Preterm Infant

Neonatal Intensive Care Units (NICUs) for very preterm infant do not provide the same living and development conditions as the intrauterine environment. preterm infant in incubators are cut off from the prenatal period; in the first moments of their aerial life, they are at odds with the normal biological continuum and immersed in an environment far removed from the intrauterine sensory world [13].
During their first days of life, these preterm infants will be confronted with numerous stress factors, such as painful care procedures and frequent and uncomfortable manipulations [13]. The preterm infant in an incubator is exposed to early sensory experiences, atypical in quantity and quality and inappropriate to his or her level of sensory maturation, whereas the temporal sequence of sensory development in utero during the 3rd trimester of gestation is well known: somesthetic and deep tactile sensitivity (proprioceptive) and chemosensory sensitivity (gustation and olfaction) at 14 weeks, vestibular sensitivity (body movement and balance) at 25 weeks, auditory sensitivity at 26 weeks, and then visual sensitivity at 28 weeks [14]. Indeed, fetal sensory experience prepares the organism to interact with the sensory environment after birth. Early mature vestibular and tactile receptors are understimulated during an incubator stay, with isolation and reduced wear time outside of skin-to-skin [14]. While immature sensory modalities in the preterm infant, such as hearing and vision, are conversely over-stimulated [15][16][17][18], including machine noises and bells and distorted voices that are amplified by the incubator walls. Early auditory experiences affect brain development; along with the noise environment of the ward, noise can be associated with tachycardia or bradycardia, apneas, decreased oxygenation, increased muscle tension, blood pressure and intracranial pressure, and sleep disturbances [19]. The noise environment exacerbates the child’s energy expenditure, induces physiological instability, and may affect hearing quality. Indeed, a stay of more than four days in the NICU is a risk factor for hearing loss [20].
Much of the physical contact (technical gestures and nursing care) is not soothing and is associated with mostly unpleasant and unfamiliar odors such as disinfectant [21][22][23][24]. Some painful procedures (blood work, catheter placement, fundus, etc.), when not balanced by sufficient exposure to positive tactile experiences, contribute to an attenuation of cortical processing of (non-harmful) tactile stimuli at discharge [25]. The incubator stay combines sensory deprivation, over-stimulation, and/or harmful, uncomfortable, or inappropriate stimulation with direct consequences on the brain maturation of the preterm newborn. Certain syndromes inherent to the health of the preterm infant, such as respiratory distress or ulcerative colitis, are the source of intense stress for both the preterm infant and the parents. All of these painful and dystimulating events are considered to be major stress factors with significant consequences on the child’s state of health, on his or her development, and on brain maturation [18][26]. Indeed, stress responses lead to greater oxygen consumption, notably through the acceleration of the heart rate [26], to the detriment of other functions such as tissue development. It is also noted that the vasoconstriction inherent in the stress response can increase intracranial pressure, associated with hypoxia, favoring the development of intraventricular hemorrhages [27].

2.1. Reduction of Sensory Stimuli

Recognition that sensory stimulation can overwhelm preterm infants and increase physiological signs of stress has led to attempts to reduce sensory input [18]. Because preterm infants have difficulty regulating their homeostasis and responding appropriately to environmental stimuli, this interferes with the development of their perceptual and self-regulatory abilities [28][29][30]. The theoretical approach of the Newborn Individualized Developmental Care Assessment Program (NIDCAP) is that the amount of stimulation that preterm babies receive is excessive [31][32]. NIDCAP is a set of strategies designed to protect the preterm infant [33]. They include environmental modifications to minimize stressful sensory stimuli for preterm infants, such as reducing bright lights, reducing loud and sudden noises, limiting temperature changes, and careful observation of the child and his or her ability to regulate care, in order to provide an individualized care program based on each child’s resources and weaknesses [31][33][34]. The NIDCAP approach takes into account the organization of four functioning systems in relation to the external environment: the autonomic system, the motor system, the arousal system, and the interactional system [33][34]. The disorganization of one of these systems as a result of stress has repercussions on the others. The positive effects of NIDCAP can be seen in the short term on weight-bearing growth, respiratory autonomy, and decrease in the length of hospitalization [28][35][36]. NIDCAP enhanced neurobehavioral and neurological development in preterm infants at two weeks of Corrected Age (CA) when compared with standard care [37]. The benefits of NIDCAP were evident at 9 months of age but did not persist at 12, 18, or 24 months of CA [36][38][39][40]. The NIDCAP intervention reduces the need for respiratory support and the length of hospital stay [18]. NIDCAP is a program that is not readily available to all NICUs because it requires extensive training and a significant time investment by caregivers [41].
Some other early intervention programs, such as that of Becker et al. [29], aim to facilitate the preterm infant’s self-regulatory abilities through sound reduction. Decreased noise in the unit and incubator reduces apneas, hypoxemia, and cardiac accelerations in low-weight, very preterm infants [42]. Reducing sound and light for 12 h at night resulted in improved weight gain and increased sleep time [43]. Noise reduction and consolidation of care to allow for longer sleep time and stress monitoring resulted in better staturo-weight gain, shorter length of hospital stay, and better performance on the Neonatal Behavioral Assessment Scale, particularly on the reflex and self-regulation scales [29]. One somewhat contradictory study found no change in physiologic parameters when auditory input was reduced by placing earmuffs on preterm infants for 2 days [44]. Autcott et al. [18] questioned what level and duration of sound exposure is harmful to the developing auditory system of a preterm infant. In animal studies, including gerbils (small rodents), Caras and Sanes [45] and Ihlefeld et al. [46] were able to test the extent to which a disturbance occurring at the very beginning of auditory function later alters behavioral performance by temporarily and partially depriving them of auditory inputs for a brief period, 12 days starting 11 days after birth (by earplugs attenuating airborne sounds by 40 dB SPL, without suppressing bone conduction and the possibility for the animal to hear its own biological sounds). Gerbils showed atypical sensory perception with impaired discrimination of sound localization [44] as well as impaired discrimination of sounds in a noisy environment [46]. In relation to the developmental difficulties of the preterm child, Mowery et al. [47] have shown that there are interactions between the critical period of development of the visual system and that of the auditory system: inducing the visual system to function prematurely disrupts the critical period of development of the auditory system; conversely, delaying the onset of function of the visual system can extend the critical period of the auditory system by several days. These data suggest that if the natural sequence of sensory function development is disrupted, as it is in very preterm infants, the critical period of auditory developmental plasticity may be altered and could lead to alterations [48].

2.2. Enrichment of Sensory Stimuli in the NICU

Other programs, on the other hand, offer soothing sensory enrichment in the NICU such as therapeutic touch, soft music, etc. [18]. These programs are based on the underlying theoretical premise that preterm infants suffer from sensory deprivation that limits their development. These stimuli must be provided while taking into account the sequential development of the sensory system [49][50][51] in order to compensate for the dystimulations of the neonatal environment.
Several sensory enrichment programs have measured improved cognitive development in infants who received these sensory stimuli. Scarr-Salapateck and Williams [52] offered babies in the NICU a combination of visual, tactile, auditory, and kinesthetic stimulation and repeated home visits upon discharge to continue early support. In the intervention group of this study, the preterm infant showed better cognitive and social performance at four and twelve months compared to the control group.
Introducing a soothing solicitation such as lullabies sung by the parent during a skin-to-skin session induces a better quality of parent–child interactions from the first session [53]. Indeed, singing stabilizes the mother’s gaze on her child with longer fixation times and favors the preterm child’s state of relaxation, with more time with eyes closed compared to skin-to-skin sessions without lullabies. Singing a lullaby during a skin-to-skin session helps to create a better synchronization of rhythms between the mother and her preterm baby [53].
The Supporting and Enhancing Sensory Experiences (SENSE) program [54] has studied the effect of positive, age-appropriate sensory input to the preterm infant. These interventions, performed by parents or a team of caregivers when parents are not available, are provided daily during hospitalization. These solicitations include massage, sound enrichment (human voice and music), olfactory enrichment with scented fabric, and vestibular and visual enrichment with dimmed lights [55][56]. Preterm infants who received the SENSE program had less asymmetry on the NeoNatal Neurobehavioral Scale NNNS and higher scores on the Hammersmith Neonatal Neurological Assessment [57], and mothers showed more confidence.

3. Between “Too Much and Not Enough”, the Right Balance in the NICU

It may seem contradictory that programs aiming at either a reduction of stimuli or an increase in stimuli have favorable consequences for the preterm child [58]. Studies show positive results with both increased and reduced stimuli on short-term physiological measures (including maturation of the alertness system), on neonatal neurobehavioral aspects, or on long-term measures of higher cognitive function [49][59]. Some programs will specifically target this state of alertness with an improvement in the organization of preterm states. Stimulatory programs induce an increase in wakefulness states, whereas those that aim to reduce demands result in an increase in sleep. More broadly, Horowitz [49] suggests that all types of interventions that respect the level of sensory maturation promote homeostasis in the preterm infant. Feldman [50] describes that too much harmful stimulation is detrimental, but too little stimulation can be detrimental, hence the term “too much and not enough”.
Existing interventions based on opposing theoretical underpinnings (inability of preterm children to assimilate multiple sensory information or, conversely, deprivation of sensory stimuli they should have received in utero) have led to opposing recommendations [41], which each have their limitations: these programs are limited to the time of the intervention and the length of hospitalization in the wards.
Whatever the theoretical basis adopted, the aim of these interventions is not to provide a preterm child with experiences that he or she has missed, but to help him or her to extract information from his or her environment by organizing active cycles of receiving adapted stimulation and rest [60].
People must try to take into account all of the recommendations and ensure that they are applied over a longer period of time while not overloading the immature neurological system of the preterm infant [61]. In order to promote early development, the consensus, which may seem obvious, suggests providing the preterm infant with stimuli that are neither “too much nor too little” but instead between lack of stimulation and over-simulation by adapting to these sensory needs. Thus, when certain external stimuli are attenuated, such as sounds, vibrations, and lights, and when familiar and pleasant touches and smells are favored, preterm infant can achieve greater well-being [50].

This entry is adapted from the peer-reviewed paper 10.3390/children10060999

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