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Management of the acoustic environment

Authors 

Sizun J, Hallberg B, Moen A, Bambang Oetomo S, Druart D, Ferrari F, Garzuly-Rieser T, Kuhn P, White R

© vanagonparts/Flickr, via CC/BY 2.0

User group

Healthcare professionals, neonatal units, hospitals, and health services

Statement of standard

A managed acoustic environment reduces stress and discomfort for infants.

Rationale

A managed acoustic environment supports the infant’s comfort and development, and improves satisfaction for parents and healthcare professionals. Before birth, the fetus is exposed to low frequency sounds which are organised and predictable maternal vocalisations, with low exposure to noise. Following birth, the newborn infant is exposed to a wide spectrum of sounds from the environment and human attendants, and relatively low exposure to maternal voice. (1) Environmental noise may comprise loud transients against a high level of background noise (above the hourly Leq 45 dBA threshold (2), which may be associated with discomfort and adversely affect development. (3–5)

Very preterm infants react to sound peaks that are 5-15 dBA above the background noise (6) and which may negatively impact their sleep. (7) Sleep is an important contributor to brain development during early infancy (8) and sleep deprivation in a poorly managed acoustic environment may have a negative long term impact on cognitive, psychomotor and behavioural development. (9) In contrast, low exposure to human or maternal voices may have a negative impact on language development. (10) Using behavioural strategies to alter the NICU environment can thus improve the comfort of the infant, sleep organisation and improve long term development. (11,12) A noisy environment may be a barrier for prolonged parental presence in the NICU (11,12) and for healthcare professionals may interfere with the quality of communication and job performance. (13)

Benefits

Short-term benefits

  • Improved comfort and sleep for infants (11–14)
  • More attractive environment for prolonged presence for parents (11,12)
  • More attractive working environment for healthcare professionals (15)

Long-term benefits

  • Improved language development (10,16)

 

Components of the standard

Component Grading of evidence Indicator of meeting the standard
For parents and family    
1. Parents and family are informed by healthcare professionals about the need of managed acoustic environment to reduce stress and discomfort for infants. (17) A (Moderate quality)
B (High quality)
Patient information sheet
       
2. Parents are encouraged to request reduction of environmental noise and loud talking near their infant. B (Moderate quality) Parent feedback
       
3. Parents and family are encouraged to talk and sing to their infant adjusted to the infant’s cues. (16,18) A (Moderate quality) Parent feedback
       
For healthcare professionals    
4. A unit guideline for managing and monitoring the acoustic environment is adhered to by all staff. B (High quality) Guideline
       
5. Training on acoustic expectation for the infant and on acoustic environment is attended by all staff. B (High quality) Training documentation
       
For neonatal unit    
6. A unit guideline for managing and monitoring the acoustic environment is available and regularly updated. (3–5) A (Moderate quality)
B (High quality)
Guideline
       
7. A culture for minimising noise and avoidance of loud and unnecessary talking by staff is established. B (Moderate quality) Parent feedback, staff feedback
       
8. A quiet hour is implemented. (13,19) A (High quality) Audit report, parent feedback
       
9. Equipment alarm sounds are decreased. (4) A (Moderate quality) Guideline
       
10. The acoustic environment is evaluated regularly to create awareness and facilitate changes. B (Moderate quality) Audit report
       
For hospital    
11. Training on acoustic expectation for the infant and on acoustic environment is ensured. (4,17,20) A (Moderate quality)
B (High quality)
Training documentation
       
12. Acoustic criteria are used to select new material, medical device, and equipment. B (Moderate quality) Guideline
       
For health service    
13. A national guideline on infant nutrition, including the importance and provision of MOM, fortification and supplementation is available and regularly updated. B (High quality) Guideline
       
14. National and European regulations take into account the combined effect on the acoustic environment from all the medical equipment used by the patient. B (High quality) Guideline
       

Where to go

Further development Grading of evidence
For parents and family  
N/A  
For healthcare professionals  
N/A  
For neonatal unit  
  • Monitor sound levels continuously within the scope of a quality improvement process.
B (Low quality)
For hospital  
N/A  
For health service  
  • Train and educate on sensory expectations of infants in relevant curricula.
B (Low quality)
   

Getting started

Initial steps
For parents and family
  • Parents and family are verbally informed and advised by healthcare professionals about how to speak, to sing and to read in a quiet voice to their infant when awake.
For healthcare professionals
  • Attend training on acoustic expectation for the infant and on acoustic environment.
  • Reflect (as individual and as a team) on possible sources of noise and how to reduce noise.
  • At the bedside, try to avoid any activities other than direct care.
For neonatal unit
  • Develop and implement a unit guideline for managing and monitoring the acoustic environment.
  • Develop information material on the acoustic environment for parents.
  • Measure the environmental noise level in different places in the unit and close to the newborn infant to evaluate the acoustic environment.
  • Establish a quiet hour.
For hospital
  • Support healthcare professionals to participate in trainings on acoustic expectation for the infant and on acoustic environment standard.
  • Use sound-absorbing materials for renovating or building NICUs.
For health service
  • Develop and implement a national guideline for managing and monitoring the acoustic environment.
 

Description

The impact of sound reduction on short term medical outcomes, on sleep patterns at three months of age, on staff performance and on parents’ satisfaction with the care needs to be evaluated in large and well-designed trials. (21) However, such trials are difficult to conduct for practical and ethical reasons. Thus, recommendations are based on the precautionary principle, as is common in environmental science. (22) The US standards on NICU design (3) recommend that in newborn infant rooms, the sound level shall not exceed an hourly equivalent sound level (Leq) of 45 dBA, sounds should not exceed 50 dBA more than 10% of the time (L10) with transient maximum sounds (Lmax) below 65 dBA. In staff work areas and family areas, and staff lounge areas, the sound level should not exceed an hourly Leq of 50 dB, an hourly L10 of 55 dB, or with transient sounds (Lmax) not over 70 dB.

Strategies to reach these recommended levels have not been studied in depth. Using high-performance sound-absorbing materials to build or renovate the NICU has been suggested (23,24) (see TEG NICU design). Single rooms seem to be quieter than open-bay rooms except for respiratory support equipment. (17,25) The continuous use of sound-monitoring equipment leads to reduction in the sound level for 2 months, but not longer. (5) Changing the behaviour of staff members and the culture of the NICU team is complex. Implementing a “quiet hour” could be a feasible first step. (13) Developmental care training could have an impact on the NICU environment.

Providing an adequate acoustic environment to hospitalised newborn infants is not only based on protecting them from the deleterious effect of noise but also to offer them a nurturing environment enabling the access to biologically meaningful sensory stimuli. (see TEG Infant- and family-centred developmental care)

Sources

  1. Lahav A, Skoe E. An acoustic gap between the NICU and womb: a potential risk for compromised neuroplasticity of the auditory system in preterm infants. Front Neurosci. 2014;8:381.
  2. Lasky RE, Williams AL. Noise and Light Exposures for Extremely Low Birth Weight Newborns During Their Stay in the Neonatal Intensive Care Unit. PEDIATRICS. 2009 Feb 1;123(2):540–6.
  3. White RD, Smith JA, Shepley MM, Committee to Establish Recommended Standards for Newborn ICU Design. Recommended standards for newborn ICU design, eighth edition. J Perinatol Off J Calif Perinat Assoc. 2013 Apr;33 Suppl 1:S2-16.
  4. Chawla S, Barach P, Dwaihy M, Kamat D, Shankaran S, Panaitescu B, et al. A targeted noise reduction observational study for reducing noise in a neonatal intensive unit. J Perinatol Off J Calif Perinat Assoc. 2017 Sep;37(9):1060–4.
  5. Degorre C, Ghyselen L, Barcat L, Dégrugilliers L, Kongolo G, Leké A, et al. [Noise level in the NICU: Impact of monitoring equipment]. Arch Pediatr Organe Off Soc Francaise Pediatr. 2017 Feb;24(2):100–6.
  6. Kuhn P, Zores C, Pebayle T, Hoeft A, Langlet C, Escande B, et al. Infants born very preterm react to variations of the acoustic environment in their incubator from a minimum signal-to-noise ratio threshold of 5 to 10 dBA. Pediatr Res. 2012 Apr;71(4 Pt 1):386–92.
  7. Kuhn P, Zores C, Langlet C, Escande B, Astruc D, Dufour A. Moderate acoustic changes can disrupt the sleep of very preterm infants in their incubators. Acta Paediatr Oslo Nor 1992. 2013 Oct;102(10):949–54.
  8. Ednick M, Cohen AP, McPhail GL, Beebe D, Simakajornboon N, Amin RS. A review of the effects of sleep during the first year of life on cognitive, psychomotor, and temperament development. Sleep. 2009 Nov;32(11):1449–58.
  9. Graven S. Sleep and brain development. Clin Perinatol. 2006 Sep;33(3):693–706, vii.
  10. Pineda RG, Neil J, Dierker D, Smyser CD, Wallendorf M, Kidokoro H, et al. Alterations in brain structure and neurodevelopmental outcome in preterm infants hospitalized in different neonatal intensive care unit environments. J Pediatr. 2014 Jan;164(1):52-60.e2.
  11. Heinemann A-B, Hellström-Westas L, Hedberg Nyqvist K. Factors affecting parents’ presence with their extremely preterm infants in a neonatal intensive care room. Acta Paediatr Oslo Nor 1992. 2013 Jul;102(7):695–702.
  12. Bertelle V, Mabin D, Adrien J, Sizun J. Sleep of preterm neonates under developmental care or regular environmental conditions. Early Hum Dev. 2005 Jul;81(7):595–600.
  13. Strauch C, Brandt S, Edwards-Beckett J. Implementation of a quiet hour: effect on noise levels and infant sleep states. Neonatal Netw NN. 1993 Mar;12(2):31–5.
  14. Thomas KA, Martin PA. NICU sound environment and the potential problems for caregivers. J Perinatol Off J Calif Perinat Assoc. 2000 Dec;20(8 Pt 2):S94-99.
  15. Westrup B, Stjernqvist K, Kleberg A, Hellström-Westas L, Lagercrantz H. Neonatal individualized care in practice: a Swedish experience. Semin Neonatol SN. 2002 Dec;7(6):447–57.
  16. Caskey M, Stephens B, Tucker R, Vohr B. Importance of Parent Talk on the Development of Preterm Infant Vocalizations. PEDIATRICS. 2011 Nov 1;128(5):910–6.
  17. Davidson JE, Aslakson RA, Long AC, Puntillo KA, Kross EK, Hart J, et al. Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU. Crit Care Med. 2017 Jan;45(1):103–28.
  18. Filippa M, Devouche E, Arioni C, Imberty M, Gratier M. Live maternal speech and singing have beneficial effects on hospitalized preterm infants. Acta Paediatr. 2013 Oct;102(10):1017–20.
  19. Brown G. NICU noise and the preterm infant. Neonatal Netw NN. 2009 Jun;28(3):165–73.
  20. Mosqueda-Peña R, Lora-Pablos D, Pavón-Muñoz A, Ureta-Velasco N, Moral-Pumarega MT, Pallás-Alonso CR. Impact of a Developmental Care Training Course on the Knowledge and Satisfaction of Health Care Professionals in Neonatal Units: A Multicenter Study. Pediatr Neonatol. 2016 Apr;57(2):97–104.
  21. Almadhoob A, Ohlsson A. Sound reduction management in the neonatal intensive care unit for preterm or very low birth weight infants. Cochrane Database Syst Rev. 2015 Jan 30;1:CD010333.
  22. Kriebel D, Tickner J, Epstein P, Lemons J, Levins R, Loechler EL, et al. The precautionary principle in environmental science. Environ Health Perspect. 2001 Sep;109(9):871–6.
  23. Ulrich RS, Zimring C, Zhu X, DuBose J, Seo H-B, Choi Y-S, et al. A review of the research literature on evidence-based healthcare design. HERD. 2008;1(3):61–125.
  24. Philbin MK. Planning the acoustic environment of a neonatal intensive care unit. Clin Perinatol. 2004 Jun;31(2):331–52, viii.
  25. Shahheidari M, Homer C. Impact of the design of neonatal intensive care units on neonates, staff, and families: a systematic literature review. J Perinat Neonatal Nurs. 2012 Sep;26(3):260–6; quiz 267–8.

November 2018 / 1st edition / next revision: 2023

Recommended citation

EFCNI, Sizun J, Hallberg B et al., European Standards of Care for Newborn Health: Management of the acoustic environment. 2018.

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