Journal of Pediatric Nursing (2016) 31, e149–e154

Sound Environments Surrounding Preterm Infants

Within an Occupied Closed Incubator
Aya Shimizu MSN a,⁎, Hiroya Matsuo PhD b
a
Department of Nursing, Graduate School of Health Sciences, Kobe University, Hyogo, Japan
b
Department of International Health, Graduate School of Health Sciences, Kobe University, Hyogo, Japan

Received 16 April 2015; revised 18 October 2015; accepted 18 October 2015

Key words:
Purpose: Preterm infants often exhibit functional disorders due to the stressful environment in
Preterm infants;
the neonatal intensive care unit (NICU). The sound pressure level (SPL) in the NICU is often much
Sound;
higher than the levels recommended by the American Academy of Pediatrics. Our study aims to
Environment;
describe the SPL and sound frequency levels surrounding preterm infants within closed incubators that
Frequency analysis;
utilize high frequency oscillation (HFO) or nasal directional positive airway pressure (nasal-DPAP)
Developmental care
respiratory settings.
Design and Methods: This is a descriptive research study of eight preterm infants (corrected
age b 33 weeks) exposed to the equipment when placed in an incubator. The actual noise levels were
observed and the results were compared to the recommendations made by neonatal experts.
Results: Increased noise levels, which have reported to affect neonates' ability to self-regulate, could
increase the risk of developing attention deficit disorder, and may result in tachycardia, bradycardia,
increased intracranial pressure, and hypoxia.
Conclusion and Practice implications: The care provider should closely assess for adverse effects of
higher sound levels generated by different modes of respiratory support and take measures to ensure that
preterm infants are protected from exposure to noise exceeding the optimal safe levels.
© 2016 Elsevier Inc. All rights reserved.

RECENT ADVANCES IN neonatal medical treatment
and nursing have significantly reduced the mortality rate
from 55.3% (1980) to 15.2% (2000) in extremely low birth
weight infants (500 g to 999 g) and from 20.7% (1980) to
3.8% (2000) in very low birth weight infants in Japan
(Horiuchi, Itani, & Ohno, 2002). Some preterm infants
survive but develop functional disorders because of the
stressful environments in the neonatal intensive care unit
(NICU). Several studies have shown that a stressful
environment could interfere with the neonates' ability to
self-regulate and could increase the risk of developing
attention-deficit hyperactivity disorder (ADHD) later in life
(Brown, 2009; Schieve et al., 2010). In particular, sudden,
⁎ Corresponding author: Aya Shimizu, MSN.
E-mail address: ashimizu@penguin.kobe-u.ac.jp.
jarring, or transient sounds may cause an unstable
physiological state, resulting in tachycardia, bradycardia,
increased intracranial pressure, and hypoxia (Brown, 2009).
Thus, improving the acoustic environment will encourage
natural growth and development in neonates.
For almost two decades, in America as well as in Japan, the
sound pressure level (SPL) in NICUs has remained much
higher than the levels recommended by the American
Academy of Pediatrics (AAP) (American Academy of
Pediatrics, 1997; Graven, 2000; Thomas, 1989; Thomas &
Uran, 2007) and the Recommended Standard for Newborn
ICU Design (Smith & White, 2001; White, 1999; White,
Smith, & Shepley, 2013). According to both guidelines, the
hourly equivalent continuous sound level (Leq) should be kept
at less than 45 A-weighted decibels (dBa), and the hourly
maximum sound level (Lmax) should be maintained at less

http://dx.doi.org/10.1016/j.pedn.2015.10.011
0882-5963/© 2016 Elsevier Inc. All rights reserved.
e150
than 65 dBa. Most studies that have evaluated SPL have
determined that the ventilator equipment, supplemental
oxygen therapy, and bed types are the major contributors to
noises in the NICU (Berens & Weigle, 1995, 1997; Thomas &
Martin, 2000; Byers, Waugh, & Lowman, 2006; Lasky &
Williams, 2009; Knutson, 2013; Wang et al., 2014). In
addition, the AAP guidelines (1997) do not address the issue of
appropriate sound frequency level (SFL). Some studies have
shown that the SFL range after birth is possibly higher than that
in the womb; sounds are possibly muted in-utero because of the
amniotic fluid (Krueger, Horesh, & Crosland, 2012). The SFL
was measured both inside and outside the closed incubator and
was seen to affect the autonomic nervous system (Kellam &
Bhatia, 2008, 2009; Livera et al., 2008). There is, however, a
lack of reports that evaluate both SPL and SFL within occupied
closed incubators, and determine to what sounds infants are
actually being exposed.
In this study, we aimed to describe the SPL and SFL in the
preterm infants on respiratory support in the following areas
a) beside the respirator (outside), b) near the neonate's head
inside the incubator with opened windows, and c) near the
neonate's head inside the incubator with closed windows.
Methods
An observational study was conducted to measure the
sounds within closed incubators occupied by preterm infants.
The present study was approved by the ethics committee of
our university. The recruitment extended from September
2013 to May 2014.
NICU Environment
NICU
In the present study, the NICU (level-III) consisted of a
21-bed unit in a large general hospital in Osaka, Japan. This
study was conducted only in the rooms for infants who were
attached to more medical equipment.
Medical Equipment
Neonates in the NICU were cared for in a closed incubator
and respiratory support was provided with a mechanical
ventilator. All neonates were placed in the same type of
incubator (Atom Infant Incubator V-2100G, Atom Medical,
Tokyo, Japan). The mechanical ventilator was selected
depending on each infant's respiratory setting requirements.
The Dräger Babylog® VN500 (Drägerwerk AG & Co.
KGaA, Lübeck, Germany) was used for high frequency
oscillation (HFO), and the Infant Flow® SiPAP™ (CareFusion,
CA, USA) was used for the nasal directional positive airway
pressure (nasal-DPAP) setting.
Study Protocol
The sound levels were measured after consent was
obtained from the parents whose preterm infants were
enrolled at 30 weeks of age (corrected age). A nurse manager
was recruited to explain this study to the parents of the
A. Shimizu, H. Matsuo
infants who met the following selection criteria: neonates
with a gestational age of less than 28 weeks at birth
(estimated by date of confinement, in turn based on fetal
ultrasound during pregnancy) and neonates occupying a
closed incubator. Parents signed an informed consent
document that described the purpose of the study, methods,
and expectations before starting the study. After the parents
provided consent, the sound scaling was conducted at least
twice, at approximately 2-week intervals. However the
infants with serious physical problems such as intraventric-
ular hemorrhage or sepsis were not included in the study
because the participating hospital had agreed to consider the
sentiments of their families. All the neonates were less than
33 weeks of corrected age during the course of the study.
This study was conducted during the daytime shift. The
nurse in charge or one of the researchers placed a covered
microphone to collect data regarding the sound levels a)
outside beside the respirator, and near the baby's head both b)
inside the incubator with open windows and c) inside the
incubator with closed windows. The total recording time was
determined depending on the intubation time, as indicated by
the chief doctor. Each sound recording was paused during the
routine patient care activities. After collection, the recordings
were analyzed in a laboratory. Based on the results of
frequency analysis, the SPL and SPF were determined.
Subjects
Seven families (including one family with twins) agreed
to participate in this study. A total of 19 measurement times
were scheduled for the 8 preterm infants; however, the
dataset of 17 measurement times (HFO, n = 8; nasal-DPAP,
n = 9; total measurement duration = 31 h 23 min) was
analyzed because the measurement was cancelled twice
due to serious physical condition of the infant on
observation. The SPL was analyzed with all sound recorded
regardless of the microphone location. On the other hand, the
SFL was analyzed only with the sound recorded when the
windows within the occupied incubators remained closed for
continuous 15 minutes, which is the longest duration to
analyze the SFL by the sound level meter.
Table 1 shows the demographic characteristic comparisons
for both the ventilator groups (HFO and nasal-DPAP). The
gestational age at birth and corrected age at observation ranged
from 22 to 28 weeks and 27 to 32 weeks, respectively. The
mean gestational age at birth, corrected age at birth, and infant
body weight at observation were significantly different
between the HFO group and the nasal-DPAP group,
(gestational age at birth: 23.3 ± 1.2 vs. 26.0 ± 2.9 weeks,
p b 0.05; corrected age at observation: 29.4 ± 1.9 vs. 31.4 ±
0.7 weeks, p b 0.01; infant body weight at observation:
838.0 ± 191.7 vs. 1052. 8 ± 177.0 g, p b 0.01).
Measurements
The sound within the closed incubator was recorded by a
sound level meter of international standards, the LA-5560 K,
which was calibrated by professionals before this study, with
Sound Environments e151

Table 1 Demographic characteristics. mean Leq inside the occupied incubators with closed
HFO (N = 8) Nasal-DPAP windows was significantly higher in the nasal-DPAP group
(N = 9) than in the HFO group (63.7 ± 3.5 vs. 49.3 ± 1.7 dBa,
p b 0.001).
Characteristics Mean ± SD Mean ± SD p-value
Gestational age at 23.3 ± 1.2 26.0 ± 2.9 ⁎ SPL According to Microphone Location in Both
birth (weeks) Respiratory Support Types
Birth weight (g) 509.0 ± 45.1 676.6 ± 226.7 n.s.
In the nasal-DPAP group, the inside Leq with closed
The number of days 43.0 ± 18.3 39.6 ± 20.7 n.s.
after birth (days) windows did not significantly differ across other locations
Corrected age at 29.4 ± 1.9 31.4 ± 0.7 ⁎⁎ when tested with the microphone. However, in the HFO
observation (weeks) group, the mean Leq inside occupied incubators with closed
Infant weight at 838.0 ± 191.7 1052.8 ± 177.0 ⁎ windows was significantly lower than when the microphone
observation (g) was beside the respirator (49.3 ± 1.7 vs. 54.2 ± 1.3 dBa,
Note: p b 0.05) (Figure 1). Moreover, in the HFO group, the
HFO = high frequency oscillation; nasal-DPAP = nasal directional mean Leq inside occupied incubators with closed windows
positive airway pressure. had the smallest standard deviation (SD) of all positions,
Leven test and t-test; p b 0.05 for all comparison between the 2 groups while the mean Leq inside occupied incubators with opened
(HFO and nasal-DPAP).
⁎ b 0.05. windows in the nasal-DPAP group had the smallest SD of all
⁎⁎ b 0.01. microphone locations.

SPL Within Occupied Incubators

a sound recording function (LA-0554) (Onosokki Co. Ltd., The SPL (the Leq calculated and averaged at 1-minute
intervals) within occupied closed incubators was calculated
Yokohama, Japan). Through frequency analysis with an
Oscope ver.2 software (Onosokki Co. Ltd.), the SPL in for each week of corrected age to identify outliers and
A-weighted slow response mode (dBa) and sound frequency compare the distributions (Figure 2). Overall, the Leq inside
(Hz) were calculated. In the present study, SPL indicated the occupied incubators with closed windows did not correlate
equivalent sound level (Leq) at 1-minute intervals, maximum with the corrected age at observation in any respiratory
sound level (Lmax) at 1-minute intervals, and minimum
sound level (Lmin) at 1-minute intervals. Based on previous
studies, a value greater than 1 kHz was considered a
high-frequency sound for the neonates (Kellam & Bhatia, Table 2 The sound pressure level according to the respiratory
2008, 2009; Livera et al., 2008). setting.
HFO Nasal-DPAP p-value
Data Analyses
Mean ± SD Mean ± SD
The chi-squared test was used for categorical comparisons
of data, and the t-test was used to assess the difference in the Beside respirator (HFO N = 5, nasal-DPAP N = 6)
Leq (dBa) 54.2 ± 1.3 64.0 ± 8.5 ⁎
means of continuous variables in each respiratory setting
Lmax (dBa) 57.3 ± 4.4 67.2 ± 8.1 ⁎
(HFO or nasal-DPAP). The correlation was assessed by
Lmin (dBa) 49.1 ± 2.5 60.7 ± 8.3 ⁎
using Pearson's product–moment correlation coefficient.
Inside with opened (HFO N = 7, nasal-DPAP N = 7)
The differences in Leq means were quantified by using
windows
one-way analysis of variance under the three conditions in Leq (dBa) 52.6 ± 4.5 63.9 ± 2.7 ⁎⁎⁎
each respiratory setting (HFO or nasal-DPAP). A p-value Lmax (dBa) 56.5 ± 6.1 67.9 ± 2.3 ⁎⁎⁎
less than 0.05 was considered statistically significant; all Lmin (dBa) 47.9 ± 2.3 61.2 ± 2.7 ⁎⁎⁎
tests were two-tailed. All statistical analyses were performed Inside with closed (HFO N = 8, nasal-DPAP N = 9)
on a personal computer with the statistical package SPSS for windows
Windows Ver.22.0 (IBM, Tokyo, Japan). The results of the Leq (dBa) 49.3 ± 1.7 63.7 ± 3.5 ⁎⁎⁎
statistical analysis were verified by an epidemiologist. Lmax (dBa) 51.8 ± 2.0 65.1 ± 3.7 ⁎⁎⁎
Lmin (dBa) 47.4 ± 1.5 62.3 ± 3.4 ⁎⁎⁎

Results Note:
HFO = high frequency oscillation; nasal-DPAP = nasal directional
SPL According to Respiratory Support Type positive airway pressure.
The mean of all sound pressure indicators (Leq, Lmax, Leven test and t-test; p b 0.05 for all comparison between 2 groups
and Lmin) was louder in the nasal-DPAP group than in the (HFO and nasal-DPAP).
HFO group under all three circumstances (beside the n.s. = not significant.
⁎ b 0.05.
respirator, inside the incubator with opened windows, and ⁎⁎⁎ b 0.001.
inside the incubator with closed windows) (Table 2). The
e152
Figure 1 Sound pressure level according to microphone location in both respiratory support types. HFO = high frequency oscillation;
nasal-DPAP = nasal directional positive airway pressure.
group. In the HFO group, the mean Leq was approximately
50 dBa; however, the mean Leq in the nasal-DPAP group
was approximately 60 dBa or greater.
SFL Within Occupied Incubators
The SFL within occupied incubators with closed windows
differed according to the respiratory support type (Figure 3). In
the HFO group, the mean SPL profile was bimodal, and most
frequency bands were less than 40 dB. In the nasal-DPAP
group, the peak sound frequency ranged from 2.5 kHz to
8 kHz, and each sound pressure was maintained at approxi-
mately 45 dB or more. The SPL in each frequency range was
significantly higher in the nasal-DPAP group than in the HFO
group (250 Hz: p b 0.05; more than 500 Hz: p b 0.001).
Discussion
Providing evidence-based developmental care for pro-
moting development and preventing morbidity in preterm
infants has been a difficult mission for health care providers
(Symington & Pinelli, 2006). Because the property of sound
involves not only SPL but also SFL (Gray, 2000), we initially
Figure 2 Sound pressure level according to respiratory support
type. HFO = high frequency oscillation; nasal-DPAP = nasal
directional positive airway pressure.* b 0.05.
A. Shimizu, H. Matsuo
believed that a multifaceted sound scale is necessary for
improving the acoustic environment, according to the AAP
guidelines (American Academy of Pediatrics, 1997; Graven,
2000; Thomas, 1989; Thomas & Uran, 2007) and Recom-
mended Standard for Newborn ICU Design (Smith & White,
2001; White, 1999; White et al., 2013). The identification of
sound properties would enable care providers to evaluate the
effects of sound on infants and subsequently take the
appropriate measures for infants in various environments
(Shahheidari & Homer, 2012). To the best of our knowledge,
this study is the first to evaluate sounds surrounding preterm
infants in closed incubators in terms of both SPL and SFL at
the same time.
The SPL Within the Occupied Incubator
The present study showed that the SPL and the corrected
age at observation (weeks) were not correlated, even though
Saunders identified a correlation between these two
Figure 3 Sound frequency level within incubators. HFO = high
frequency oscillation; nasal-DPAP = nasal directional positive
airway pressure.
Sound Environments
parameters (Saunders, 1995). The SPL was, however,
affected by respiratory settings (HFO or nasal-DPAP) and varied
significantly according to the mean gestational age at birth,
corrected age at birth, and infant body weight at observation.
Noninvasive respiratory management has recently been
implemented for preterm infants to prevent pneumomedias-
tinum, and nasal-DPAP, rather than HFO, is being used in
smaller infants (Waskosky & Huey, 2014). Our results
showed that the nasal-DPAP setting is louder than the HFO
setting. In fact, the nasal-DPAP sound level in the present
study failed to meet the AAP (1997) and Recommended
Standard for Newborn ICU Design recommendations for
appropriate noise levels.
In addition, in the nasal-DPAP setting, there was no
significant difference in the SPL whether the microphone
was outside the incubator, near the neonate's head inside the
incubator with opened windows, or near the neonate's head
inside the incubator with closed windows. On the other hand,
in the HFO setting, the SPL near the neonate's head inside
the incubator with closed windows was significantly lower
than the SPL beside the respirator (outside), although it was
not lower than inside the incubator with open windows. In
cases of noninvasive respiratory management such as
nasal-DPAP, the SPL inside occupied incubators with closed
windows may depend on internal, rather than external, sound
sources.
The SFL Within the Occupied Incubator
Overall, sound within the incubator was louder in the
nasal-DPAP group than the HFO group, with particularly
striking differences in the high-frequency range. Considering
that high SFL is uncomfortable even for adults, the effect of
SFLs on infants early after birth merits even greater concern,
as they were not exposed to such sounds while in the womb.
In addition, the sound study group recommended SFL for
pregnant women to protect the fetus (Graven, 2000). Preterm
infants' inability to cope with high SFL may affect their
development; thus, while the AAP does not offer SFL-
related recommendations, some appropriate limits should be
considered.
Measures to Reduce Noise Exceeding Optimal Levels
This study showed that the nasal-DPAP generated loud
sounds. The present study pointed out that a reasonably loud
sound level could be assumed due to the high sound pressure at
the high-frequency range, even though previous studies noted
that this was caused only by the SPL of tangent sound such as
higher Leq and Lmax and longer L10 (Byers et al., 2006; Lasky
& Williams, 2009). Furthermore, we demonstrated that the
main sound source in the nasal-DPAP group originated inside
the incubator, since the internal SPL with closed windows was
not significantly lower than the external SPL. Although most
nurses already strive to reduce the level of sound outside the
incubators by using incubator covers and avoiding conversa-
tion, these measures may be insufficient for reducing SPL in
e153
the nasal-DPAP setting. Thus, we should consider alternatives
for reducing ambient noise; a) use of sound absorbing
materials inside the incubator to help reduce noise level; b)
reduce the mechanical noise generated by the equipment
through improved equipment design; c) and better isolation of
the noise generating equipment from the incubator. In addition,
we propose maintaining optimal SPL and SFL that should
depend on the characteristics of the sound and be maintained
through regular measurements to prevent infants being
exposed to loud sounds (Almadhoob & Ohlsson, 2015). We
should also include individual measurements and education for
health care providers to gain knowledge regarding the current
research (Philbin, Robertson, & Hall, 1999; Philbin & Klass,
2000; Philbin & Gray, 2002).
Limitations
This study had some limitations. Even though the number
of participants was almost significantly different between
HFO and nasal-DPAP, the small sample size at the hospital
caused sample selection bias. Even though the number of
participants included in this study was low at this hospital,
we could not involve patients from another hospital, since the
expensive equipment for sound scaling was not easily
portable. In addition, the evaluation to scale sounds in NICU
was based on the AAP guidelines (1997), which is the most
popular among medical care providers worldwide; however,
it might be advisable to be updated after evaluating infants'
behaviors or physical reactions within the occupied incuba-
tors, which is the topic of our ongoing study.
Conclusion
Our results showed that noise levels affect neonates'
ability to self-regulate, can increase the risk of attention
deficit disorder, and may result in tachycardia, bradycardia,
increased intracranial pressure, and hypoxia. The care
provider should carefully assess for adverse effects of higher
sound levels such as SPL and SFL generated by different
respiration support equipment and take measures to ensure
that preterm infants are not exposed to noise exceeding the
optimal safe levels.
Acknowledgments
The authors would like to thank the neonates, their
parents, and the medical staff members for their cooperation.
This study was funded by the Japan Society for the
Promotion of Science (JSPS) KAKENHI (26861921),
Grant-in-Aid for Young Scientists (B). The funding source
had no role in study design; in the collection, analysis and
interpretation of data; in the writing of the report; and in the
decision to submit the article for publication.
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