Supporting and Enhancing NICU Sensory Experiences (SENSE), 2nd Edition: An Update on Developmentally Appropriate Interventions for Preterm Infants

The SENSE program was initiated in 2017 to promote consistent, developmentally appropriate, evidence-based positive sensory experiences for premature infants in the NICU. The program empowers parents as the center of interventions, with concrete roles and expectations to improve infant outcomes.

The 2nd edition published in 2022 is a revision of the initial program after a review of 57 articles, clinician feedback, and a survey of stakeholders, including: neonatologists, nurse practitioners, clinical nurse specialists, bedside nurses, occupational therapists, physical therapists, speech-language pathologists and parents.  Adjustments were made to allow for variability in light levels between hospital units

Updated Visual Recommendations:

  • Light Protection
    • Avoid direct or bright lights throughout hospitalization
    • Avoid continuously dark environment at any time period
    • Previous recommendation for lights off prior to 32 weeks eliminated
  • Cycled Lighting
    • Initiate at 32 weeks PMA, changed from 12 hours on/off to:
      • ON “during the day” and OFF “during the night”
      • No specific times or number of hours recommended, to allow staffing flexibility for what works best on their unit, such as on for day shift and off for night shift, or on when the sun is up and off when the sun is down
  • Light Levels
    • Daytime light levels: ‘moderate office light’ around 250 lux either by way of natural light or artificial light
    • Nighttime light levels:  darkness at or less than 25 lux
  • Light Transitions
    • Gradual changes recommended since sudden changes in light can disrupt and impact sleep
    • Use a dimmer switch, curtains or a blanket to allow for a gradual change in light
  • Promotion of Vision
    • Face-to-Face interaction with a parent starting at 34 weeks
    • Human face should be the focus of the interaction, instead of a toy
Pineda, R., Keller, P., Ibrahim, C., SENSE Advisory Team Working Group, & Smith, J. (2023). Supporting and enhancing NICU experiences (SENSE), 2nd edition: An update on developmentally appropriate interventions for preterm infants. Children, 10, 961.

Visual Alertness and Brain Diffusion Tensor Imaging at Term Age Predict Neurocognitive Development at Preschool Age in Extremely Preterm Born Children

Premature infants are at risk for neurodevelopmental differences or deficits due to an interruption in normal development of the structure and function of the brain. These can be manifested through cognitive, motor, behavioral, and social impairments. Sensory pathways are developed early and quickly, with vision being one of the earliest to develop.  Preterm infants are at a high risk for visual processing disorders even without visual impairments.

Purpose: Researchers set out to examine the relationship between visual abilities at term age, brain white matter structures, and neurocognitive outcomes.

Subjects: 20 extremely preterm infants (<28 weeks), treated in the NICU in Helsinki University Hospital in Finland between May 2006 and September 2008. None of the participants were blind, deaf or had cerebral palsy.

Methods: Pediatric neurologist exam at term age, assessing visual alertness with a black and white bullseye pattern, rating the infant to have optimal or nonoptimal alertness.  At 6.5 years of age, children were reassessed using the Wechsler Preschool and Primary Scale of Intelligence Scale for Children (subtests included: executive functioning, sensorimotor functioning, visuospatial processing, and social perception).  Whole brain diffusion-weighted MRI were also performed on each participant.

Outcomes: 10 of the participants demonstrated optimal visual alertness at term age.  Gender and morbidity did not play a role in alertness. When examined at 6.5 years of age, those with optimal visual alertness at term age demonstrated clinically notable differences in: sensorimotor function test, imitating hand positions, visuospatial processing tests, social perception and affect recognition as compared to those who showed nonoptimal alertness at term age.  A statistical linear correlation (p<0.05) was noted between different white matter bundles on the dMRI and neuropsychological performance at 6.5 years of age.  Children with optimal alertness had higher white matter bundles than those with nonoptimal alertness.

Conclusion: Optimal visual alertness at term age was related to higher white matter bundles and structure of the whole brain. Damage to the white matter in the occipital area has been correlated with impaired executive functioning at school age. Difficulties imitating hand positions for games or play and recognizing affect, expression and emotions can greatly impact social development.

Aho, L., Sairanen, V., Lonnberg, P., Wolford, E., Lano, A., Metsaranta, M. (2023). Visual alertness and brain diffusion tensor imaging at term age predict neurocognitive development at preschool age in extremely preterm born children. Brain and Behavior, e3048. https://doi:10.1002/brb3.3048

Development of the Motor Functions of Children Without Visual Impairment and Visually Impaired Children

Motor skills help to manifest abilities, behavior, and personality.  The greatest influences on motor skills are interactions with family, stimulation from the environment, nutrition, socioeconomic factors, parent relationships and involvement with the children. Visual imitation also impacts the development of motor skills such as walking, expression, games, and activities in everyday life.

Purpose: To determine the differences in motor functions between those with visual impairment and those without visual impairment.

Subjects: 70 participants between the ages of 7 and 15 years of age.  35 with visual impairment and 35 without visual impairment.

Methods: Participants from Sarajevo were assessed by researchers utilizing the LNNB-C scale to examine motor function across a variety of tests including motor speed and dexterity, kinesthesia, imitation, knowledge of bodily wholeness, oral motor skills, quality and speed of drawing, and coordination of movements from verbal commands. Data obtained was processed through a statistical computer program.

Results: Statistical significance was found (p<0.05) between the 2 groups in: alternative activity, quality of drawing, and speed of drawing and motor skills. A statistical correlation (p=0.01) was found between the 2 groups for drawing quality and drawing speed.

Conclusion: Motor skills are generally better developed in those without visual impairments. Among those with visual impairments, the best developed motor function were oral motor skills and the least developed was quality of drawing.

Alibegovic, R. (2023). Development of the motor functions of children without visual impairment and visually impaired children. Human Research in Rehabilitation. 13(1), 69-71.

Final Thoughts

Visual impairments have long-term implications for neurocognitive development and motor skills—and it’s not just about visual acuity! Visual perception is key and relates to later learning, reading, and social-emotional awareness that affects our daily interactions. These articles highlight the importance of new recommendations for light levels, cycled lighting, and providing age-appropriate visual activities in the NICU. Remember, supporting visual development involves more than ROP exams and visual tracking. Know Better. Do Better.

What you do every day in the NICU matters and impacts long-term developmental outcomes. As an NTMC professional you can use these articles to guide your practice, advocate for environmental changes in your unit, and educate parents on how to best support their infant’s visual development in the NICU, and beyond.

Your Friends in Neonatal Care,

The NTMC Team