Supporting and Enhancing NICU Sensory Experiences (SENSE)
Supporting and Enhancing NICU Sensory Experiences (SENSE) is a comprehensive approach to ensuring multi-modal positive sensory exposures across hospitalization for high-risk infants in the NICU. The SENSE program provides education to engage families in providing developmentally appropriate positive sensory exposures to optimize outcomes for their infant(s). Topics of education include: medical terminology, fetal development in the final months of pregnancy, the sensory environment of the NICU, sensory development, reading infant cues, identifying readiness for sensory exposures, how to provide different sensory exposures, and a week-by-week guide* on specific doses and timing of sensory exposures to ensure consistent and developmentally appropriate delivery of positive sensory experiences at each postmenstrual age. The sensory interventions are designed to be provided by parents, but the medical team and/or volunteers can also be engaged to ensure the sensory needs of each infant are met.
In addition to the education materials and week-by-week guide, log sheets for parents, the medical team, and volunteers are provided to track the positive sensory exposures that are implemented each week. Although specific doses of positive sensory exposures are identified in the guide, it can be individualized for each infant based on the preferences of the family and/or the medical status/tolerance of the infant. An assessment of sensory tolerance is also included in the SENSE program package. The weekly assessment, which can be conducted more often when needed, aims to ensure that the infant tolerates the week-by week sensory exposures as described, and it also provides guidance on how to identify adaptations to sensory exposures when necessary. The assessment is designed to be conducted by a physical or occupational therapist with neonatal expertise or by another designated health care professional.
High-risk infants who receive care in the neonatal intensive care unit (NICU) are exposed to significant stressors that include painful procedures, disruption of normal sensory experiences, and stress related to parent-infant separation. There is growing concern that these alterations in the early environment, during a period of rapid brain development, can negatively impact developmental outcomes.
In an environment where stimuli are primarily negative, positive sensory exposures and parent-infant interaction are crucial and can have life-long implications on learning, memory, emotions, and developmental progression. It is well understood that multi-dimensional sensory exposures are present in utero in the final months and weeks of pregnancy, but an infant born preterm misses those potentially important, timed exposures that may be absent or altered in the NICU environment.
While the use of positive sensory exposures, such as massage, auditory exposure, and skin-to-skin care have been related to better parent and infant outcomes, a guideline that describes specific doses and targeted timing of positive multi-modal sensory exposures across all the days, weeks or months of hospitalization was needed. The SENSE program was developed to fill that need.
The SENSE program is a comprehensive, standardized guideline on providing developmentally appropriate and timed sensory exposures for preterm and high-risk infants who are hospitalized in the NICU. The guideline can be initiated immediately after birth and used throughout NICU hospitalization. Education materials are designed for the family. The baby assessment is designed to be conducted by a physical or occupational therapist with neonatal expertise or other designated medical professional.
- Descriptive and comprehensive education aimed at informing and engaging parents in providing developmentally appropriate sensory exposures to their infant(s).
- Evidence-based week-by-week sensory interventions that adjust with postmenstrual age.
- Materials that can be individualized based on the needs of each NICU.
- The written materials available in the SENSE package include: a booklet for parents, log sheets to track sensory exposures, and a weekly infant assessment. An electronic version of SENSE is also available that enables education materials to be pushed to a personal computer, smartphone, or tablet. The electronic version has videos that demonstrate the described interventions.
The week-by-week guide was developed after a rigorous process of protocol development. This included an integrative review that outlined 88 articles on sensory-based interventions (auditory, tactile, vestibular, visual, kinesthetic, and olfactory/gustatory) that were used with preterm infants to improve outcome, expert input from a multidisciplinary group of 108 health care professionals that defined sensory interventions implemented across different NICUs, 3 multidisciplinary focus groups that provided a critical review of the guidelines, and interviews with 20 parents of preterm infants who gave input on the feasibility of implementing the SENSE guideline in the NICU. The week-by-week guide ensures that the type and timing of different sensory exposures are tailored to infants based on their developmental needs. A pilot study of 30 preterm infants using the finalized SENSE protocol demonstrated feasibility and preliminary evidence of a positive impact on parent confidence and infant neurobehavior. Analysis of data from a randomized clinical trial, which will identify infant and parent outcomes longitudinally, is nearing completion.
Liszka, L., Heiny, E., Smith, J., Schlaggar, B. L., Mathur, A., & Pineda, R. (2020). Auditory exposure of high‐risk infants discharged from the NICU and the impact of social factors. Acta Paediatrica, 109(10), 2049-2056. https://doi.org/10.1111/apa.15209 Show abstract
Aim. To (a) define the early home auditory environment of high‐risk infants within one month of neonatal intensive care unit (NICU) discharge, (b) compare auditory exposures in the home environment to the NICU environment, and (c) define relationships between maternal/infant factors and auditory exposures within the home.
Methods. Seventy‐three high‐risk infants (48 high‐risk infants in the NICU at term‐equivalent age and 25 high‐risk infants in the home following NICU discharge) had auditory exposures measured.
Results. An average of 1.3 hours more noise (P ≤ .001) and 2 hours less silence (P = .01) were observed in the NICU compared with the home, but differences varied based on whether comparing to an open ward or private room. Infants with public insurance, lower household income and mothers without a college education were exposed to an average of 2.8, 3.0 and 2.3 hours more TV/electronic sounds respectively (P < .05). An average of 1744 fewer adult words (P = .03) were spoken in households with public insurance. There was an average of 3.1 hours less silence and 4.5 dB louder stimuli among households with lower income (P < .05).
Conclusion. Elucidating differences across environments can lead to interventions to foster appropriate auditory exposures to improve language development of high‐risk infants.
Pineda, R., Wallendorf, M., & Smith, J. (2020). A pilot study demonstrating the impact of the supporting and enhancing NICU sensory experiences (SENSE) program on the mother and infant. Early Human Development, 144, 105000. https://doi.org/10.1016/j.earlhumdev.2020.105000 Show abstract
Aim. To explore differences in maternal mental health and infant neurobehavioral outcome among infants who received and did not receive the Supporting and Enhancing NICU Sensory Experiences (SENSE) program.
Study design. Eighty preterm infants (50 receiving standard-of-care and 30 receiving the SENSE program) born ≤32 weeks gestation were enrolled within the first week of life in a prospective quasi-experimental design, using a historical control group for comparison. Standard-of-care consisted of tactile (skin-to-skin, touch, holding) and olfactory (scent cloth, close maternal contact) interventions as determined to be appropriate by health care professionals and parents. The SENSE group received specific doses of tactile (skin-to-skin care, holding, massage, touch), auditory (human speech, music), olfactory (scent cloth, close maternal contact), kinesthetic/vestibular (movement, rocking/transfers), and visual (dim or cycled light) exposures, based on the infant's postmenstrual age and tailored to medical status and infant cues according to the SENSE program. The SENSE program includes the intentional delivery of positive, age-appropriate sensory exposures by parents (or a sensory support team, when parents are unavailable) each day of NICU hospitalization. Infant neurobehavioral outcome, as well as maternal mental health and confidence, were assessed prior to NICU discharge, using standardized measures.
Results. Seventy-three infants were included in the final analysis. Mothers whose infants received the SENSE program demonstrated higher scores on the Maternal Confidence Questionnaire (p = 0.01). Infants who received the SENSE program demonstrated less asymmetry on the NICU Network Neurobehavioral Scale (p = 0.02; mean difference 0.9) and higher scores on the Hammersmith Neonatal Neurological Evaluation (p < 0.001; mean difference 4.8).
Discussion. Preliminary evidence demonstrates improvements in maternal confidence and infant neurobehavioral performance following SENSE implementation.
Pineda, R., Roussin, J., Heiny, E., & Smith, J. (2019). Health care professionals' perceptions about sensory-based interventions in the NICU. American Journal of Perinatology, 36(12), 1229-1236. https://doi.org/10.1055/s-0038-1676536 Show abstract
Objective. The main objective of this article is to define perceptions of health care professionals regarding current use of sensory-based interventions in the neonatal intensive care unit (NICU).
Study Design. A multidisciplinary group of NICU health care professionals (n = 108) defined the types of sensory-based interventions used in their NICU, the postmenstrual age (PMA) sensory-based interventions are administered, conditions under which sensory-based interventions are used, and personnel who administer sensory-based interventions.
Results. The most commonly reported tactile intervention was infant holding (88% of respondents), the most common auditory intervention was recorded music/singing (69% of respondents), the most common kinesthetic intervention was occupational and physical therapy (85% of respondents), and the most common vestibular intervention was infant swings (86% of respondents). Tactile interventions were initiated most often at 24 to 26 weeks PMA (74% of respondents), auditory interventions at 30 to 32 weeks (60% of respondents), kinesthetic interventions at 30 to 32 weeks (76% of respondents), vestibular interventions at 33 to 34 weeks (86% of respondents), and visual interventions at 32 to 36 weeks (72% of respondents). Conditions under which sensory-based interventions were administered, and personnel who provided them, varied across settings.
Conclusion. Varied use of sensory-based interventions in the NICU were reported. While this study was limited by biased sampling and the identification of health care professionals' perceptions but not real-world practice, this information can be used to build a comprehensive approach to positive sensory exposures in the NICU.
Liszka, L., Smith, J., Mathur, A., Schlaggar, B. L., Colditz, G., & Pineda, R. (2019). Differences in early auditory exposure across neonatal environments. Early Human Development, 136, 27-32. https://doi.org/10.1016/j.earlhumdev.2019.07.001 Show abstract
Background. To date, no study has compared preterm and full term auditory environments.
Aim. To define differences in auditory exposure for preterm infants at term equivalent age in the neonatal intensive care unit (NICU) compared to auditory exposure in hospital rooms on a labor and delivery ward after full term birth.
Study design. Ninety-eight infants (48 preterm infants born 28 weeks gestation in the NICU at term equivalent age and 50 full term infants in a hospital room on the labor and delivery ward within 4 days of birth) had auditory exposure measured over a single 16-hour period using the Language Environment Acquisition (LENA) device.
Results. More language (p < 0.001) was observed on the labor and delivery ward than in the NICU, with an average of 3.3 h more language in a 16-hour period and an average of 14,110 more words spoken around infants in a 16-hour period on the labor and delivery ward (p < 0.001). More electronic sounds were observed in the NICU, with an average of 2.3 h more in the 16-hour period (p < 0.001). The average decibel level in the NICU was lower than in the hospital rooms on the labor and delivery ward (57.16 ± 2.30 dB, compared to 63.31 ± 2.22 dB; p < 0.001).
Conclusion. The NICU auditory environment for preterm infants is different than the auditory environment for full term infants, with less language, more electronic sounds, and quieter stimuli. This understanding can aid in developing appropriate interventions that enhance positive forms of auditory exposures.
Clubbs, B., Barnette, A., Gray, N., Weiner, L., Bond, A., Harden, J., & Pineda, R. (2019). A community hospital NICU developmental care partner program: Feasibility and association with decreased nurse burnout without increased infant infection rates. Advances in Neonatal Care, 19(4), 311-320. https://doi.org/10.1097/ANC.0000000000000600 Show abstract
Background. Volunteers can provide staff-directed sensory inputs to infants hospitalized in the NICU, but research on volunteer programs is limited.
Purpose. To evaluate the feasibility of a developmental care partner (DCP) program in a level III NICU and determine its relationship with provider burnout and infant infection rates.
Methods. DCPs were trained to provide sensory input to infants, based on the behavioral cues observed by the occupational therapists and nursing staff, in medically stable infants. Feasibility was assessed by documenting the process of training and utilizing volunteers, as well as tracking duration and frequency of DCP visits. Staff burnout measures were assessed using the Maslach Burnout Inventory Human Services Survey (MBI-HSS) before and after implementation. Infant infection rates before and after the introduction of volunteers were compared.
Results. Seventy-two volunteers were interested, and 25 (35%) completed the DCP competencies and provided sensory exposures to 54 neonates, who were visited an average of 8 times (range 1-15). Twelve (48%) DCPs did once-per-week visits, and 9 (36%) did at least 50 contact hours. MBI-HSS scores for staff emotional exhaustion (P < .001) and depersonalization (P < .006) were lower after DCP implementation. There were no differences in infant infection rates before and after DCP implementation (Fisher exact P = 1.000).
Implications for Practice. Volunteer-based DCP programs may be feasible to implement in community hospitals and could help reduce staff emotional exhaustion and depersonalization without increasing the incidence of infant infections.
Implications for Research. Future research on NICU volunteer programs with larger sample sizes and different infant populations is warranted.
Pineda, R., Raney, M., & Smith, J. (2019). Supporting and enhancing NICU sensory experiences (SENSE): Defining developmentally-appropriate sensory exposures for high-risk infants. Early Human Development, 133, 29-35. https://doi.org/10.1016/j.earlhumdev.2019.04.012 Show abstract
Introduction. There is evidence to support the use of positive sensory exposures (music, touch, skin-to-skin) with preterm infants in the neonatal intensive care unit (NICU), but strategies to improve their consistent use are lacking. The Supporting and Enhancing NICU Sensory Experiences (SENSE) program was developed to promote consistent, age-appropriate, responsive, and evidence-based positive sensory exposures for the preterm infant every day of NICU hospitalization.
Methods. A systematic and rigorous process of development of the SENSE program included an integrative review of evidence on sensory exposures in the NICU, stakeholder feedback, expert opinion, and focus groups.
Results. SENSE implementation materials consist of parent education materials, tailored doses of sensory exposures for each postmenstrual age, an infant assessment of tolerance, bedside logs and implementation considerations for integrating the SENSE program into the NICU.
Discussion. Research is needed to evaluate the SENSE program as an implementation strategy and to assess its impact on parent and infant outcomes.
Pineda, R., Bender, J., Hall, B., Shabosky, L., Annecca, A., & Smith, J. (2018). Parent participation in the neonatal intensive care unit: Predictors and relationships to neurobehavior and developmental outcomes. Early Human Development, 117, 32-38. https://doi.org/10.1016/j.earlhumdev.2017.12.008 Show abstract
Objective. To 1) define predictors of parent presence, any holding, holding in arms, and skin-to-skin care in the NICU and 2) investigate the relationships between parent participation and a) early neurobehavior and b) developmental outcomes at age 4 to 5 years among preterm infants.
Methods. Eighty-one preterm infants born ≤ 32 weeks estimated gestational age were prospectively enrolled within one week of life in a level III–IV NICU. Parent (maternal and paternal) presence and holding (including holding in arms and skin-to-skin care) were tracked throughout NICU hospitalization. Neurobehavior at term equivalent age and development at 4 to 5 years were determined using standardized assessments.
Results. The median number of days per week parents were documented to be present over NICU hospitalization was 4.0 (IQR = 2.4–5.8) days; days held per week 2.8 (IQR = 1.4–4.3) days [holding in arms days per week was 2.2 (IQR = 1.2–3.2) days and parent skin-to-skin care days per week was 0.2 (IQR = 0.0–0.7) days]. More parent presence was observed among mothers who were Caucasian, married, older, or employed and among those who had fewer children, familial support and provided breast milk (p < 0.05). More holding was observed in infants with fewer medical interventions (p < 0.05) and among those who were Caucasian, had a father who was employed, had fewer children and family support (p < 0.05). More parent holding in the NICU was related to better reflex development at term age (p = 0.02). More parent skin-to-skin care was related to better infant reflexes (p = 0.03) and less asymmetry (p = 0.04) at term and better gross motor development (p = 0.02) at 4–5 years.
Discussion. Social and medical factors appear to impact parent presence, holding, and skin-to-skin care in the NICU. Parent holding is related to better developmental outcomes, which highlights the importance of engaging families in the NICU.
Keywords. Neonatal intensive care unit; Preterm; Parent engagement; Participation; Development; Holding; Skin-to-skin care; Presence; Visitation; Outcomes; Environment; Attachment
Ryckman, J., Hilton, C., Rogers, C., & Pineda, R. (2017). Sensory processing disorder in preterm infants during early childhood and relationships to early neurobehavior. Early Human Development, 113, 18-22. https://doi.org/10.1016/j.earlhumdev.2017.07.012 Show abstract
Background. Preterm infants are exposed to a variety of sensory stimuli that they are not developmentally prepared to handle, which puts them at risk for developing a sensory processing disorder. However, the patterns and predictors of sensory processing disorder and their relationship to early behavior at term equivalent age are poorly understood.
Objectives. The aims of the study are to: 1) describe the incidence of sensory processing disorder in preterm infants at four to six years of age, 2) define medical and sociodemographic factors that relate to sensory processing disorder, and 3) explore relationships between early neurobehavior at term equivalent age and sensory processing disorder at age four to six years.
Methods. This study was a prospective longitudinal design. Thirty-two preterm infants born ≤ 30 weeks gestation were enrolled. Infants had standardized neurobehavioral testing at term equivalent age with the NICU Network Neurobehavioral Scale. At four to six years of age, participants were assessed with the Sensory Processing Assessment for Young Children (SPA).
Results. Sixteen children (50%) had at least one abnormal score on the SPA, indicating a sensory processing disorder. There were no identified relationships between medical and sociodemographic factors and sensory processing disorder. More sub-optimal reflexes (p = 0.04) and more signs of stress (p = 0.02) at term equivalent age were related to having a sensory processing disorder in early childhood.
Conclusion. Preterm infants are at an increased risk for developing a sensory processing disorder. Medical and sociodemographic factors related to sensory processing disorder could not be isolated in this study, however relationships between sensory processing disorder and early neurobehavior were identified.
Keywords. NICU; Sensory processing disorder; Neurobehavior; Prematurity
Pineda, R., Guth, R., Herring, A., Reynolds, L., Oberle, S., & Smith, J. (2017). Enhancing sensory experiences for very preterm infants in the NICU: an integrative review. Journal of Perinatology, 37, 323–332. https://doi.org/10.1038/jp.2016.179 Show abstract
Objective. Very preterm infants hospitalized in the neonatal intensive care unit (NICU) experience alterations in sensory experiences. Defining types, timing and frequency of sensory-based interventions that optimize outcomes can inform environmental modifications. The objective of this study was to conduct an integrative review on sensory-based interventions used with very preterm infants in the NICU to improve infant and parent outcomes.
Study Design. The data sources include MEDLINE, CINAHL, Cochrane Library and Google Scholar. Studies were identified that used sensory-based interventions in the NICU with preterm infants born ⩽32 weeks gestation, were published in a peer-reviewed journal between 1995 and 2015, and measured outcomes related to infant and parent outcomes. Studies were extracted from electronic databases and hand-searched from identified reference lists.
Results. Eighty-eight articles were identified (31 tactile, 12 auditory, 3 visual, 2 kinesthetic, 2 gustatory/olfactory and 37 multimodal). There was evidence to support the use of kangaroo care, music and language exposure, and multimodal interventions starting at 25 to 28 weeks postmenstrual age. These interventions were related to better infant development and lower maternal stress, but not all findings were consistent. Limitations included lack of consistent outcome measures, study quality and gaps in the literature.
Conclusions. Most research identified interventions that were done for short periods of time. It is unclear what the potential is for improving outcomes if positive sensory exposures occur consistently throughout NICU hospitalization. Until more research defines appropriate sensory-based interventions to use with infants born very preterm in the NICU, information from this review can be combined with expert opinion and parent/family values to determine best practice.
Pineda, R., Durant, P., Mathur, A., Inder, T., Wallendorf, M., & Schlaggar, B. L. (2017). Auditory exposure in the neonatal intensive care unit: Room type and other predictors. The Journal of Pediatrics, 183, 56-66.e3. https://doi.org/10.1016/j.jpeds.2016.12.072 Show abstract
Objective. To quantify early auditory exposures in the neonatal intensive care unit (NICU) and evaluate how these are related to medical and environmental factors. We hypothesized that there would be less auditory exposure in the NICU private room, compared with the open ward.
Study design. Preterm infants born at ≤ 28 weeks gestation (33 in the open ward, 25 in private rooms) had auditory exposure quantified at birth, 30 and 34 weeks postmenstrual age (PMA), and term equivalent age using the Language Environmental Acquisition device.
Results. Meaningful language (P < .0001), the number of adult words (P < .0001), and electronic noise (P < .0001) increased across PMA. Silence increased (P = .0007) and noise decreased (P < .0001) across PMA. There was more silence in the private room (P = .02) than the open ward, with an average of 1.9 hours more silence in a 16-hour period. There was an interaction between PMA and room type for distant words (P = .01) and average decibels (P = .04), indicating that changes in auditory exposure across PMA were different for infants in private rooms compared with infants in the open ward. Medical interventions were related to more noise in the environment, although parent presence (P = .009) and engagement (P = .002) were related to greater language exposure. Average sound levels in the NICU were 58.9 ± 3.6 decibels, with an average peak level of 86.9 ± 1.4 decibels.
Conclusions. Understanding the NICU auditory environment paves the way for interventions that reduce high levels of adverse sound and enhance positive forms of auditory exposure, such as language.
Keywords. preterm; senses; environment; language
Smith, J. R., & Pineda, R. G. (2016). Determining appropriate sensory exposures in the NICU: Too much, too little, or just right? [Editorial]. Neonatal Network, 35(2), 63-65. https://doi.org/10.1891/0730-08184.108.40.206
Pineda, R. G., Neil, J., Dierker, D., Smyser, C. D., Wallendorf, M., Kidokoro, H., Reynolds, L. C., Walker, S., Rogers, C., Mathur, A. M., Van Essen, D. C., & Inder, T. (2014). Alterations in brain structure and neurodevelopmental outcome in preterm infants hospitalized in different neonatal intensive care unit environments. The Journal of Pediatrics, 164(1), 52-60.e2. https://doi.org/10.1016/j.jpeds.2013.08.047 Show abstract
Objective. To evaluate associations between neonatal intensive care unit (NICU) room type (open ward and private room) and medical outcomes; neurobehavior, electrophysiology, and brain structure at hospital discharge; and developmental outcomes at 2 years of age.
Study design. In this prospective longitudinal cohort study, we enrolled 136 preterm infants born <30 weeks gestation from an urban, 75-bed level III NICU from 2007-2010. Upon admission, each participant was assigned to a bedspace in an open ward or private room within the same hospital, based on space and staffing availability, where they remained for the duration of hospitalization. The primary outcome was developmental performance at 2 years of age (n = 86 infants returned for testing, which was 83% of survivors) measured using the Bayley Scales of Infant and Toddler Development, 3rd Edition. Secondary outcomes were: (1) medical factors throughout the hospitalization; (2) neurobehavior; and (3) cerebral injury and maturation (determined by magnetic resonance imaging and electroencephalography).
Results. At term equivalent age, infants in private rooms were characterized by a diminution of normal hemispheric asymmetry and a trend toward having lower amplitude integrated electroencephalography cerebral maturation scores (P = .02; β = −0.52 [CI −0.95, −0.10]). At age 2 years, infants from private rooms had lower language scores (P = .006; β = −8.3 [CI −14.2, −2.4]) and a trend toward lower motor scores (P = .02; β = −6.3 [CI −11.7, −0.99]), which persisted after adjustment for potential confounders.
Conclusion. These findings raise concerns that highlight the need for further research into the potential adverse effects of different amounts of sensory exposure in the NICU environment.
Applications: Neonatology, Intervention Tools, Research Tools
Keywords: sensory integration, sensory enrichment, education, parent engagement, NICU, preterm, high risk infants
Innovator(s): Bobbi Pineda, PhD, OTR/L, CNT
Copyright 2017 by Washington University in St. Louis, Missouri. All rights reserved. The SENSE program was created at Washington University in St. Louis.
The University of Southern California has licensed the rights to the SENSE program, including exclusive permission for public distribution.
Download a preview of the SENSE parent education materials.
Purchase of the SENSE program also includes electronic access to allow the program materials to be downloaded and printed. Additionally, an electronic version of the parent education materials (MS PowerPoint format) containing embedded videos can be downloaded for use with families in your hospital. Parent education materials are provided for download in both English and Español.
Supporting & Enhancing NICU Sensory Experiences (SENSE) program
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Preprinted parent education books are available for purchase, for those hospitals that have already purchased the program. These are not intended to be used without careful attention to safety and implementation, as contained in the implementation package received upon purchase of the SENSE program. Please verify that you or your hospital purchased the SENSE program in order to proceed with purchasing preprinted parent education materials.
Additional parent education books (English)
1 copy, $15
2 to 8 copies, $12 each
9 to 49 copies, $10 each
50 or more copies, $9 each
Additional parent education books (Español)
1 copy, $15
2 to 8 copies, $12 each
9 to 49 copies, $10 each
50 or more copies, $9 each