Beyond Survival: Improving Social Development in Preterm Infants

December 20, 2018
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The NICU can save lives but impair social development for extremely preterm infants.

While essential for survival, the neonatal intensive care unit (NICU) can be a technologically driven and minimally social environment for preterm infants. In a new study, researchers from Nationwide Children’s Hospital report that the care structure received by extremely preterm infants in the NICU can have long-term effects on social competence and dysregulation.

In the NICU, extremely preterm infants (born with gestational ages less than 27 weeks) are attached to extensive tubing and monitoring wires and are placed in isolettes. This often results in dysregulation, such as abrupt changes in oxygen saturation and heart rate, and places them at a social developmental disadvantage. For instance, extremely preterm infants are at a higher risk than full-term babies for exhibiting neurodevelopmental impairments such as autism spectrum disorders.

“If you think about an extremely preterm baby, they could be spending 120 days in the NICU,” says Jenn Gonya, PhD, senior research scientist at Nationwide Children’s and co-author of the new study. “To develop their social brain, they need human social interaction, but when they are in the NICU, they don’t experience all the necessary pieces to develop appropriate social and emotional outcomes.”

Dr. Gonya and her colleagues set out to quantify the human environment of the NICU and identify associations between the care structures received by extremely preterm infants and their social competence at two years of age. The researchers analyzed the quantity and type of human interaction experienced by 50 extremely preterm infants during their first 30 days of life in the NICU. When the participants were two years old, the researchers administered the Brief Infant-Toddler Social and Emotional Assessment (BITSEA), a parent self-report questionnaire used to evaluate social-emotional development.

The analysis revealed that extremely preterm infants spent the majority (80 percent) of their time alone, with nursing care comprising most of their human interaction. The infants who did receive more human interaction had significantly higher social competence scores and lower dysregulation scores on the BITSEA at age two. Even an extra 20 minutes of high-quality human interaction, especially skin-to-skin contact, made a difference in later BITSEA scores.

“Skin-to-skin care is an extra or add-on to many people – something nice for parents to do,” Dr. Gonya says. “But this study helps demonstrate that it is a critical component of development that needs to happen.”

Dr. Gonya says that babies this premature have essentially missed out on the third trimester in the womb, where they would normally have a regulated, highly interactive environment. All the medical technology of the modern NICU can keep them medically regulated, but there is more to healthy growth and development.

“We have to look at their development holistically and understand that we have a responsibility to develop the whole human,” she says. “Having them survive is not enough. A social developmental component has to be part of standard of care. We need to make sure there are not long-term consequences from medical care and procedures.”

Dr. Gonya emphasizes that everyone involved in the care of premature babies, from parents to nurses to doctors, has a responsibility to provide high quality human interaction. And as this study demonstrates, even small changes to care can translate into much larger outcomes later on.

“In order to inject more humanity into the process, it only takes a small change in mindset and priorities to adjust how we actually provide care,” she says. “Social competence doesn’t show up on a monitor, but it is crucial for developing a healthy human brain.”

Dr. Gonya and her team say further research is needed to understand how primary care nursing, early therapeutic intervention, and skin-to-skin care may synergistically play a positive role in social development in the NICU. Future studies should investigate ways to increase meaningful human interactions with extremely preterm infants in the NICU.



Gonya J, Feldman K, Brown K, Stein M, Keim S, Boone K, Rumpf W, Ray W, Chawla N, Butter E. Human interaction in the NICU and its association with outcomes on the Brief Infant-Toddler Social and Emotional Assessment (BITSEA). Early Human Development 2018; 127:6-14. Doi: 10.1016/j.earlhumdev.2018.08.010.

Image credit: Nationwide Children’s