Description and evidence on the supporting and enhancing neonatal intensive care unit sensory experiences (SENSE) program

Abstract

Aim

To describe the supporting and enhancing neonatal intensive care unit (NICU) sensory experiences (SENSE) program, associated research and opportunities for further study.

Methods

A review of current materials on SENSE program implementation, publications related to SENSE development, and research on program implementation and patient outcomes was conducted to describe the SENSE program and its associated research.

Results

The SENSE program combines structured, evidence‐based, multisensory interventions with parent engagement in order to optimise outcomes in the complex NICU environment. Through a stepwise and scientific process, the SENSE program was developed to include specific doses and targeted timing (based on the infant's postmenstrual age, PMA) of evidence‐based interventions such as massage, auditory exposure, rocking, holding and skin‐to‐skin care for parents to provide their infants each day of NICU hospitalisation. It is adapted in context of concurrent medical interventions, infant behavioural responses, as well as NICU culture. The program is feasible to implement, acceptable to staff, and related to infants receiving more developmentally appropriate sensory exposures. Adaptations related to NICU culture and parent involvement have been reported. Research has identified relationships of the SENSE program to improved parent confidence, neurobehaviour and feeding at term age as well as improved communication 1 year of age.

Conclusion

The literature related to the SENSE program is promising, but more research on efficacy and implementation is needed.

Abbreviations

aEEG

amplitude‐integrated electroencephalography

MRI

magnetic resonance imaging

NCAFS

Nursing Child Assessment Feeding Scale

NICU

neonatal intensive care unit

NNNS

NICU Network Neurobehavioral Scale also known as NeoNatal Neurobehavioral Scale

PMA

postmenstrual age

QR code

quick response code

SENSE

supporting and enhancing NICU sensory experiences

TIDieR

template for intervention description and replication

Key Notes.

• The supporting and enhancing neonatal intensive care unit (NICU) sensory experiences (SENSE) program was developed in 2017 (updated in 2022) and engages parents in providing evidence‐based, developmentally appropriate and positive sensory exposures to their infant each day of NICU hospitalisation.

• The SENSE program is feasible to implement, results in higher amounts of positive sensory exposures, and is acceptable to parents and healthcare professionals.

• There are relationships between SENSE programming and parent confidence, short‐term outcomes and feeding.

1. INTRODUCTION

The neonatal intensive care unit (NICU) environment exposes sick and immature newborns, including very preterm infants, to intense, painful and repeated stimuli as they receive life‐sustaining medical interventions. ¹ This adverse environment can have deleterious effects on early brain structure and function, ¹ , ² which negatively impacts a host of important developmental outcomes. ³

Preterm birth also affects parents, as they spend the first months of their child's life deferring to healthcare providers in the NICU ⁴ and experiencing challenges that can make it difficult for them to interact with their infant. Subsequently, parents of preterm infants are at heightened risk for stress, ⁵ depression, ⁶ anxiety ⁷ and post‐traumatic stress. ⁸ Limited engagement in the infant's care can further exacerbate anxiety and stress, prompting coping through withdrawal or avoiding participation in care. ⁹ Alterations in parent‐infant interaction can lead to poor child social–emotional development, attachment insecurity ¹⁰ and maternal mental health concerns. The importance of maternal–child interactions on language development is also well documented, ¹¹ as mother–infant interaction impacts the parent–child relationship and early sensory exposures, which are tied to the infant's developmental skill acquisition. ¹²

Many hospitals aim to reduce sensory stimuli to the infant, but research has determined that low‐stimulation NICU environments with poor parent engagement can also negatively impact outcomes, specifically language outcomes. ² Further, an environment focused on minimising interactions with the infant while providing invasive and painful medical interventions can result in a lasting footprint of negative early stimuli on the developing brain. Therefore, balancing reductions of negative stimuli while providing positive and developmentally appropriate sensory experiences is important in order to provide the best environment for the growing, preterm infant in the NICU. In this vein, there is strong evidence that positive sensory interventions (skin‐to‐skin contact, massage and music) may mitigate procedural pain and discomfort, improve brain development, and enhance parent and infant outcomes. ¹³ Positive sensory exposures in the environment trigger electrocortical activity, which then impacts brain development, which can lead to better infant neurodevelopmental outcomes. Despite such evidence, most positive sensory interventions for preterm infants in the NICU are implemented inconsistently or for short periods of time, which limits their impact. ¹⁴

The Supporting and Enhancing NICU Experiences (SENSE) program was developed in response to the need for a care environment aimed at optimising the early sensory environment for the infant and engaging parents in positive and developmentally appropriate interactions with their infants to improve their health and well‐being and that of their infant. The aim of this manuscript was to describe the SENSE program, associated research and opportunities for further study.

1.1. Background/Rationale for SENSE programming

The infant's need for human contact and nurturing has long been understood. Animal studies have identified that even brief periods of maternal separation can result in emotional disturbances and decreased motor activity among offspring. ¹⁵ Clinical studies on early parent–infant interactions have also demonstrated the positive effects of parent interaction on the motor responses of the infant. ¹⁶ Early deprivation of quality social and caregiver interaction has been shown to have lasting effects, leading to poor physical growth, developmental delay and increased emotional and neurocognitive difficulties. ¹⁷ Additionally, abnormalities have been found among orphaned newborns using magnetic resonance imaging. ¹⁸ Although vulnerable preterm infants differ from children who have been institutionalised or deprived of caregiving attention after full‐term birth, they share striking similarities, including altered temporal structures and high risk of impairments related to motor, cognitive, and psychosocial development. ¹⁸

Parent involvement is an important modifiable factor in the NICU, as infants whose parents are present and engaged in infant care and interaction in the NICU demonstrate more favourable outcomes. ¹⁹ Previous research has identified that those at the highest risk for decreased parental presence in the NICU are the infants of young or unmarried mothers and those who are African–American/Black, ¹⁶ highlighting the importance of ensuring the spread of interventions to those who have known health disparities. Having more children to care for at home can also be a barrier to parent participation in the NICU. ¹⁶ Finally, organisational barriers can include the culture of care in the NICU, which can influence parental presence. ⁹ , ²⁰ Even when parents are present in the NICU setting, they still may not be able to fully engage with their infant, as they may lack the confidence and knowledge to do so. The result can be months of hospitalisation in a sensory‐deprived environment, which can alter the long‐term developmental trajectory of the infant. In addition, this can further contribute to the parents' feelings of depression and lack of confidence in their role as parents. ²¹ , ²²

While parent presence is developmentally supportive, high‐risk infants in the NICU are still at risk of sensory deprivation when parents are at the bedside. Within a medicalised environment, high‐risk infants may not be held or engaged with in ways or amounts that optimise their development. ¹⁹ Additionally, other models of NICU care may emphasise a reduction in sensory exposures and may fail to fully elucidate the need for positive sensory exposures. Further, variations in NICU environments, such as single patient rooms versus an open ward, can lead to different infant sensory needs. For example, our previous work has demonstrated significant reductions in positive auditory exposures and poorer language outcomes among infants hospitalised in single patient NICU rooms. ² , ²³

Parent presence is a critical aspect of developmentally appropriate stimulation for hospitalised infants, and intentional parental involvement should be prioritised. The SENSE program was developed in response to research that identified parent presence and engagement in the NICU as a critical aspect of care that is often suboptimal. ¹⁶ , ¹⁹ This, combined with the identified sensory needs of the high‐risk infant that could be supported by the parent's involvement in their care, led to the development of the SENSE program, which aims to optimise the environment through parents supporting the developmental needs of their infant. Prior to its development, there was no other comprehensive, evidence‐based program that identified types and amounts of daily sensory exposures for preterm infants in the NICU based on developmental age. Parents are intended to be the primary drivers of the SENSE program and guided in appropriate, evidence‐based strategies to engage in with their infants each day. ²⁴ The SENSE administrator educates families on what, how and when to provide the sensory exposures, ensures the infant can tolerate the recommended sensory exposures, and updates the programming as medical challenges are resolved and the infant matures.

The aim of this manuscript is to describe the Supporting and Enhancing NICU Sensory Experiences (SENSE) program, associated research and opportunities for further study.

2. METHODS

A review of current materials associated with SENSE program implementation as well as a review of publications related to the development of the SENSE program was conducted. A traditional online search was conducted to identify websites that outline information on the SENSE program. Research studies on the SENSE program were identified through a search for articles on Google Scholar, Scopus, Web of Science, Psych as well as PubMed. Keywords used included ‘SENSE program’ and ‘Supporting and Enhancing NICU Sensory Experiences’. The review included articles and information on the SENSE program from 2017, when the SENSE program was developed, to March 2024. Articles were incorporated into this review if they included measures of implementation (such as adoption, cost, penetration), parent outcomes (such as parent stress scores) or infant outcomes (such as neurobehavioral scores) in relation to the SENSE program. Articles that were identified also had their reference lists checked for other articles that may have reported on implementation, efficacy or benefits of the SENSE program. Further, current studies that are underway (and known to the authors of the SENSE program) were identified and reported. From this information, this manuscript describes what the SENSE program entails, how it was developed, what the associated research has identified in terms of its implementation and infant and parent benefits, and opportunities for additional study.

3. RESULTS

3.1. What is the SENSE program?

The SENSE program combines the need for parent engagement in the NICU with the infant's need for consistent positive multisensory exposures. The SENSE program defines a cohesive, evidence‐based, parent‐delivered program for the application of positive multisensory exposures each day of hospitalisation in the NICU. This multisensory program aims to empower and engage parents, including those at the highest risk, to provide age‐appropriate and evidence‐based positive sensory exposures during their infant's development in the NICU by implementing a comprehensive sensory diet that is articulated in easy‐to‐understand language.

3.2. How to obtain the SENSE program

The SENSE program requires a user fee that supports the cost of distribution. After paying the user fee, the NICU is granted access to a website enabling the user to print off all the materials in any quantity needed. Quick response (QR) codes for parent education materials in each available language are also provided. In addition, each user is sent a hard copy of the parent education materials, bedside materials, and an administration and implementation guide. Finally, a mobile application of the SENSE program (SENSE NICU) is also available and provides the SENSE education and a space for parents to locally store their documented sensory exposures with their baby. Information on the SENSE program is available here: https://chan.usc.edu/nicu/sense.

3.3. SENSE administrator

Individuals serving in the role of SENSE administrator provide ongoing parent education, assess the infant's ability to tolerate the program as defined, and make modifications as appropriate. The SENSE administrator is the main driver of implementation at the organisational level and is a necessary role to assign when working towards SENSE program implementation. Some NICUs may assign the role to one SENSE administrator, while others may have several SENSE administrators within their NICU. The SENSE administrator can be any licensed healthcare professional with specific knowledge on developmental progression of preterm infants from birth to term, medical complications and interventions, how to read and respond to infant cues, and an understanding of positioning, handling, and sensory exposures. This clinician must have a strong knowledge base of the range of medical conditions and interventions that are seen in the NICU as well as strong confidence and expertise with infant handling and sensory interventions. They must also have effective communication and education skills to inspire parental engagement and to support healthcare professionals in promoting positive sensory exposures within the NICU environment. The program was developed to focus tasks needed for the SENSE program onto a SENSE administrator, while respecting the limited bandwidth of multiple team members with other clinical responsibilities. While the SENSE administrator oversees the program and engages the parents in being the main driver of providing the positive sensory experiences contained within the SENSE program, full team‐buy in and engagement optimises the implementation of the program within the NICU.

Previous research involving preterm infants <32 weeks in a level IV NICU identified that the SENSE administrator had an average of 4.8 (±3.7) educational sessions with families, amounting to 72.3 (±37.4) total minutes over hospitalisation.

3.4. Training of healthcare professionals

All healthcare professionals providing care in the NICU can be trained on the SENSE program including bedside nurses, neonatal therapists, neonatologists, respiratory therapists, dieticians, nurse practitioners, social workers, psychologists, Child Life specialists and music therapists. However, it is typical for one or two disciplines (or individuals) to take on the role of SENSE administrator while the others function as supports (i.e. the occupational therapists may be the SENSE administrator and educate the parents on the program, but it may be the bedside nurse who aids the transfer of the infant from bed to parent's chest for kangaroo care to meet the daily sensory doses defined). Materials were developed with the intent that training on the SENSE program could involve healthcare professionals reading and reviewing the 88‐page implementation and administration manual and/or watching the introduction video provided on the back end of the website. While SENSE administrators are not required to undergo additional training, there are training workshops available to guide them in SENSE implementation. ²⁵

Due to requests for in‐person training, a 1‐day virtual webinar and a 1‐day in‐person hospital training were developed and are now available at nicutherapylab.com. ²⁵

3.5. Parents as the primary driver of the SENSE program

The SENSE administrator provides education and support to the parents and assesses the infant's tolerance of the interventions as described at the start of the program and at least weekly thereafter. More frequent family and infant check‐ins and education by the SENSE administrator may occur when acute changes in medical status occur.

The main driver of the program is intended to be the parents, who provide the minimum daily targets of tactile, auditory, visual, olfactory and kinesthetic/vestibular interventions each day. For example, at term age, the following is recommended: at least 3 h of tactile exposure (kangaroo care, holding, hand hug or massage), at least 3 h of auditory exposure (reading/singing/speaking to infant or music), at least 3 h of olfactory exposure (parent or breast milk scent), visual exposure (enface positioning with attempts to focus and track parent's face, cycling light, protecting from direct and bright light), and kinesthetic exposure (being in at least four different positions for at least 10 min each, one of which to include tummy time; eight opportunities for free movement outside the swaddle for at least 2 min; rocking for at least 7 min). When parents are unable to engage fully in providing the specified amount of each sensory exposure, a sensory support team can be utilised to ensure the infant continues to receive daily doses of positive sensory exposures. The sensory support team can be made up of trained volunteers, Cuddlers or medical/therapy students who provide the agreed‐upon sensory interventions to the infants in the NICU.

Although the SENSE program includes specific amounts of sensory exposures to provide each day, the sensory interventions defined in the SENSE program are intended to be immersed in the daily routines within the NICU and are tailored to the needs of the individual infant based on level of immaturity, concurrent medical interventions and tolerance of handling.

3.6. SENSE program development

The SENSE program was developed through a rigorous process of program development. This first included an integrative review of the evidence from 1995 to 2015 that outlined 88 articles on sensory‐based interventions (auditory, tactile, vestibular, visual, kinesthetic and olfactory/gustatory) that were used with preterm infants to improve infant development or parent outcomes. ¹⁴ While the comprehensive review of articles over a 20‐year period included information pertaining to a wide range of sensory interventions provided in the NICU as well as a variety of outcomes, the SENSE program includes only those that had supporting evidence and that went through another stage of expert review.

After identifying sensory interventions from the literature, as well as the timing (postmenstrual age) of those interventions conducted in the NICU, expert input was sought from a multidisciplinary group of 108 healthcare professionals that defined sensory interventions implemented across different NICUs. ²⁶ These healthcare professionals also provided a critical review of the first edition of the SENSE program. Then, interviews with 20 parents of preterm infants provided input on the feasibility of implementing the SENSE program in the NICU. ²⁷ These parent perceptions were probed among potential intervention users after the full development of the program (review of evidence and expert input). Finally, perceptions about feasibility were probed through three multidisciplinary focus groups of healthcare professionals in a level IV NICU. ²⁸ Modifications to the program were made at each stage, as each step led to new discoveries that led to improvements. The finalised version of the SENSE program was achieved after the last step in the process, the focus groups with healthcare professionals on perceptions about feasibility.

3.7. Parent education materials

Parent education materials consist of an 88‐page booklet written at a 5th to 8th grade reading level that includes a glossary of common NICU terms along with chapters that detail the importance of parental involvement, development of the senses, specific guidelines for providing sensory experiences, and guidance on when to interact based on their infant's cues. The booklet also includes a ‘how to’ guide with recommendations for sensory experiences to share with their baby each day of hospitalisation with minimum target ‘doses’ that evolve across postmenstrual age (PMA), and detailed instructions and videos for how to share sensory experiences (such as massage or gentle rocking) with their baby. The week‐by‐week guide within the parent education materials defines the type and timing of evidence‐based sensory exposures that are tailored to infants based on their developmental needs. The main component of the program includes the type and timing of different sensory exposures each day of hospitalisation, as depicted below for an infant at 23 weeks PMA (see Figure 1). However, see below (implementation and administration guide) for information on how the program is further adapted based on medical status, behavioural responses and NICU culture.

FIGURE 1.

The week‐by‐week guide of sensory support for an infant at 23 weeks postmenstrual age.

The parent education materials are currently available in English, Spanish, Arabic, French, Korean, Hindi, Chinese, Hebrew and German, with additional translations ongoing. In addition to a print version of the booklet, these materials are also accessible electronically via a QR code to enable easy access on smart phones and/or tablets. The intent is for parents to use the SENSE program educational materials, along with direct education and support from the SENSE administrator, to engage in providing sensory interventions within the SENSE program to their infants with additional support provided as needed by other members of the healthcare team. Within the parent education materials, a chapter is dedicated to reading and responding to infant behavioural cues, so that the program is led by the infant and individualised.

3.8. Implementation and administration guide and other implementation materials

The implementation and administration manual is a supplemental resource that serves as a ‘user manual’ for clinicians to implement and support the program, with information regarding the development of the program, strategies for implementation, and adaptations that can be made to the program. The manual guides clinicians in three main subsections: components of the program, necessary personnel, and materials to assist in implementation. Specific information about sensory exposure and intensity is included. The manual also includes strategies for engaging families and celebrating small progress towards positive sensory exposures. It outlines recommendations to integrate the program into the context of daily life in the NICU. The guide will continue to be updated as new knowledge is generated.

Within the implementation materials, an implementation flow diagram aids in guiding NICUs to define NICU personnel, contexts for different sensory interventions, and an administration plan. Every NICU is different in terms of staffing, average length of stay, populations served, acuity and culture. Therefore, different adaptations at the organisational level may aid in implementation. The guide assists with understanding the adaptations that are made in the real‐world context based on unit policies (such as not supporting out‐of‐bed activities in the first 72 h of life or needing to use gloves with any infant contact) versus the context of adaptations that may actually alter the SENSE program itself (adding additional non‐evidence‐based interventions to the repertoire or changing the amount of time for minimal targets). The implementation and administration guide identifies pitfalls, the context in which they have been reported, and what other NICUs did to overcome them. The guide also identifies a process towards implementation, suggesting manageable activities that can be incorporated into the daily flow of the NICU and then expanded as traction is gained.

How well each NICU implements the program is based on a multitude of different factors. In addition, NICUs may first choose to implement part of the program and then to build on their successes as they gain confidence. Each hospital has a different starting point. When positive sensory exposures and education are already a part of care, hospitals may be able to achieve full implementation with ease. For hospitals engaged in little or no developmental care practices, there may be much to do in order to achieve full implementation. When this is the case, celebrating the small successes and the journey towards improved care should be applauded when implementing the SENSE program clinically.

3.9. Documenting sensory exposures in the NICU

Within the implementation and administration guide, there are log sheets available for tracking sensory exposures to ensure the minimum doses of sensory exposure identified in the SENSE program are being met each day (see Figure 2). This is a place for parents or healthcare professionals to track such exposures across each day of hospitalisation. In addition, a SENSE app (NICU SENSE) is being trialled to capture the amounts of sensory exposures as is the use of tracking within RedCap and the electronic medical record.

FIGURE 2.

Daily sensory log for infant at 23 weeks postmenstrual age.

3.10. Infant assessment

Also within the implementation and administration guide, there is an infant assessment, which includes a framework for deciding if infants are tolerating the sensory exposures as depicted in the SENSE program at the individual level. This framework can be used to guide the SENSE administrator, but other methods of assessing tolerance, including gestalt perception, can also be used. The infant assessment of tolerance forms the basis for determining if the infant can handle the SENSE program as defined or if adaptations to the programming are needed. Other research has demonstrated that 95% of high‐risk infants in a level IV NICU could tolerate the SENSE program as it is defined, but 5% of infants needed temporary adaptations. ²⁵ A few infants required temporary discontinuation of interventions for reasons including surgical intervention, redirection of care, and repetitive physiological compromise that was not directly related to sensory exposures. In all instances, the sensory interventions were started up again within 1–2 weeks. ²⁵

3.11. Adaptations/tailoring

The interventions that have evidence to support their use are listed for each sensory system in the SENSE program. This provides choices for families who may have different preferences. The program enables adaptations to occur in the context of different organisational policies and cultures (e.g. choosing only hand hugs as the tactile exposure during the first 72 h of life or not allowing massage as a choice if massage is not an accepted practice in a specific NICU).

Individualised adaptations to the SENSE program can be defined based on the assessment of tolerance, which is done at least weekly (by the SENSE administrator) or more often when acute changes in medical status occur. Although modifications to program delivery may be indicated, they should be made within the context of medical necessity in order to ensure a safe environment for the infant. However, the goal is to provide the daily doses of intervention each day of hospitalisation using the evidence‐based intervention options provided. When something like holding is not recommended, other tactile exposures that count towards the total tactile dose can be used, such as hand hugs. Modifications to the program that don't impact such fidelity are ideal, where all the doses described are completed.

3.12. Assessing fidelity

The SENSE program differs from the standard of care because it entails a specific, targeted amount of each sensory exposure to be delivered each day of hospitalisation. This is different from the variable application of sensory exposure as part of routine care. When calculating doses of sensory interventions during standard of care compared to the SENSE program, treatment differentiation is evident, with infants in the SENSE program receiving significantly more sensory exposures than those receiving standard of care. ²⁵ Fidelity can be assessed through documentation of sensory exposures on bedside logs, in the medical record, within other electronic systems (Redcap surveys or SENSE NICU app) as well as through other healthcare professional or research team documentation that identifies the type and amount of each daily sensory exposure. Differences among those receiving and not receiving the program can be determined to assess treatment differentiation. Fidelity can be assessed by determining the percentage of the recommended dose of each sensory exposure that was achieved. This is useful predominantly for tactile and auditory exposures, since they have large discreet doses. As a process towards full implementation, accepting small changes in the total percentage of the sensory exposures achieved may be acceptable. However, working towards >75% of the recommended doses being achieved is ideal.

3.13. Keeping the program updated based on emerging evidence

The SENSE program was made available to clinicians in 2017 after the first integrative review and the stepwise process towards program development were completed (see previous section ‘SENSE program development’). To keep the SENSE program updated based on emerging literature, the SENSE program will be assessed for changes every 5 years. The second version of the SENSE program was launched in 2022. This was after another integrative review identified an additional 58 articles published between 2015 and 2020. ²⁹ Following the review of new articles, a SENSE advisory team of 27 stakeholders (consisting of neonatologists, nurse practitioners, nurses, occupational therapists, physical therapists, speech‐language pathologists and parents) was formed to aid in ensuring the SENSE program was evidence‐based and incorporated the current published literature, remained appropriate for different types of families, and was applicable and relevant to different NICUs. Although changes from the original SENSE program were made in 2022, the most recent evidence did not contradict the existing recommendations. However, there were some additions and refinements of language, including adding positioning changes to the kinesthetic options, removing specific light levels from the cycled light recommendation, using gender‐neutral language, and using verbiage that is inclusive for different family structures. ³⁰

3.14. Description of the intervention based on the TIDieR guidelines

To aid in better understanding the specifics of the SENSE program in a condensed and easy‐to‐understand format, we have outlined the intervention based on the TIDieR guideline (see Table S1). The TIDieR guideline enables a clear, concise description of the SENSE program in order to allow for its replication. However, due to its complex nature, those implementing it should refer to the comprehensive materials available on the SENSE website once the user fees have been paid and access has been granted. This table was completed based on SENSE program clinical implementation rather than describing it in terms of a research study and can aid in understanding what reasonable adaptations can occur to facilitate implementation.

3.15. Evidence of the feasibility, acceptability and other implementation factors

Within the research team that developed the SENSE program, the program was shown to be feasible to conduct with preterm infants ≤32 weeks in a Level IV NICU. ³¹ It was also deemed to be acceptable and was adopted by both healthcare professionals and parents of preterm infants in the NICU. ²⁵ Only 5% of the infants in a level IV NICU required individualised adaptations or a break from the program that lasted <1–2 weeks, with 95% of infants able to tolerate the SENSE program as it is described. Interestingly, the earlier parents were educated on the SENSE program after birth, the more parent engagement was observed throughout hospitalisation. ²⁵ Further investigation demonstrated that for younger mothers and parents living further away from the hospital, participation in the SENSE program was positively associated with increased parental engagement and presence within the NICU. ³²

Another study investigated relationships between parent and infant outcomes based on whether SENSE program interventions occurred most often between parent–infant dyads or provider/volunteer–infant dyads. ³³ Using a cohort of 35 preterm infants born <32 weeks gestation, infants whose parents conducted most of the SENSE interventions had less lethargy on the NICU Network Neurobehavioral Scale at term age, and their parents had lower scores on the Parental Stress Scale and State–Trait Anxiety Inventory‐state compared to those who had most of the interventions conducted by healthcare professionals or volunteers.

While quantitative studies largely investigate the relationship of an intervention to an outcome, implementation studies investigate how the intervention performs in the real‐world context and is used by the population for whom it is designed. Other research investigating implementation has occurred outside the original study site and among the program authors. de Castro et al. ³⁴ investigated the feasibility of adapting the SENSE program with eight pairs of parents and infants in a Level III NICU. The SENSE administrator assessed the infant's tolerance at least each week and conducted parent education at least every week (or more often if the infant had a change in medical status). As SENSE doses of sensory exposures were not consistently met, the SENSE program was adapted to incorporate a daily 1‐h session of sensory intervention, administered by the manuscript's author, in cases where a parent was unavailable. Recruitment and retention rates were high. The recruitment and initial education averaged 37.5 min. The time for the weekly assessment averaged 22.5 min and the weekly parent education took an average of 13.8 min. ³⁴

Patel and her team conducted a study to evaluate the impact of the SENSE program on 110 preterm infants (55 control and 55 treatment), their parents and medical staff in the NICU. They found that caregivers who received the SENSE program felt better prepared for the transition home and were more satisfied with their infants' care. Further, healthcare professionals identified that the SENSE program education materials improved their ability to deliver care and provide appropriate information to parents at the bedside. ³⁵

A few doctoral dissertations and theses have centred work on SENSE program implementation. Nicole Moseley Jaeger evaluated the SENSE program with 38 parent‐infant dyads at a Level II NICU. One of her objectives was to educate NICU personnel about neurodevelopment and the SENSE program in order to provide developmentally supportive care. Their findings showed enhanced staff education throughout the NICU, which resulted in implementation of the SENSE program with 84% of families receiving SENSE program education by the second day of life. However, they found that frequent adjustments were necessary to facilitate family‐centred sensory care and incorporate the SENSE program into everyday schedules. ³⁶ Blackman ³⁷ conducted observations, informal interviews, distributed a questionnaire for the multidisciplinary team, and undertook weekly audits of SENSE implementation over a 6‐week period. More than half of surveyed employees reported being aware of the benefits, feeling confident implementing the SENSE protocol, and reported that all five senses within the SENSE program were easy to implement (with olfactory being reported as the most difficult to implement). Most of the staff responded that there are daily barriers to implementing the SENSE program. There were role discrepancies as to whose responsibility it was to initiate SENSE education to the parents, but the SENSE binder was present at the bedside among >90% of beds in 4 of the 6 weeks audited.

In addition to the aforementioned studies on the implementation of the SENSE program, a survey was sent to 215 SENSE administrators who were healthcare professionals and had obtained the SENSE program prior to March 2020. ³⁸ Respondents were neonatal therapists, nurses, neonatal nurse practitioners, neonatologists or other associated professionals from different NICUs. Among those who had obtained the program and were surveyed, 53% had implemented the SENSE program. Thirty‐one percent experienced quick timing (<1 month) from obtaining to implementing the program, and an additional 35% of respondents indicated that most infants in their NICUs received the program within 6 months of implementation. In this article, factors related to implementation across different hospital systems are described. Barriers to SENSE program implementation included a lack of team buy‐in and changes in the unit. Facilitators included rolling out the program in small pieces, getting buy‐in, and educating all disciplines. Thirty‐three percent of healthcare professionals indicated that they made adaptations to facilitate the implementation of the SENSE program. None of the respondents hired additional staff to implement the SENSE program, and no costs (aside from the initial user fee) related to SENSE program implementation were identified. On the individual level, most respondents reported that the program was implemented with families within 3 days of birth or upon admission and that parents and therapists (occupational therapists, physical therapists, and speech‐language pathologists) provided the majority of the recommended sensory interventions. ³⁸

3.16. Efficacy and SENSE program benefits

Although the SENSE program was developed based on current evidence on sensory‐based interventions for preterm infants in the NICU, it is important to have research to identify its benefits as a comprehensive program. Here, we identify studies that have investigated the impact of the SENSE program.

To our knowledge, only one adequately powered randomised clinical trial has been conducted to determine program efficacy. Seventy very preterm infants (born <32 weeks) were enrolled within 1 week of birth and randomised to the SENSE program or to standard of care. Infant neurobehaviour and parent mental health (stress, anxiety and depression) and confidence were assessed when the infant was term age. Parent mental health and infant developmental outcomes were assessed via parent‐reported measures at 1 year of corrected age. The infants receiving the SENSE program had higher lethargy scores on the NICU Network Neurobehavioral Scale (NNNS‐II; completed at term equivalent age) after controlling for social and medical risk. In addition, these infants had higher communication scores (as measured on the Ages and Stages Questionnaire) on univariate analysis at 1‐year corrected age. ³⁹ While the study was not powered for multivariate analysis, communication scores were no longer significant after controlling for social and medical risk. Different assessment tools were used at 1 year of age, as those used at term do not extend beyond this developmental time period. While lethargy may be commonly regarded as an unfavourable indication of neurobehavioral functioning, such a finding could be consistent with other research on kangaroo care being related to increased sleep. ⁴⁰

The study authors also conducted a pilot study of 80 preterm infants prior to the randomised clinical trial. This included 30 very preterm infants (born <32 weeks) who received the finalised SENSE program and were compared to 50 historical controls who did not receive the SENSE program. Infants who received the SENSE program demonstrated better neurobehaviour at term age, and parents whose infants received the SENSE program demonstrated more confidence on a self‐reported measure of parent confidence. ³¹

Another study conducted by the program authors studied the impact of parents doing the SENSE interventions on stress levels. Parent stress during SENSE program interventions was measured in 17 preterm infant–parent dyads using electrodermal sensors applied to the parents' wrist. Pre‐intervention (baseline), during the intervention and post‐intervention concurrent measures of stress were obtained. In general, parents did not appear to demonstrate significant stress when conducting SENSE program interventions with their infants. Although some small spikes in parent stress responses were observed in some parents at the beginning of an intervention, stress levels returned fairly quickly to baseline. ⁴¹

In attempting to elucidate challenges in the measurement of parent–infant interaction, Richter et al reported on findings from the Nursing Child Assessment Feeding Scale (NCAFS) in 26 preterm infants who received the SENSE program or standard of care. There were no relationships between parent mental health measures and parent–infant interaction per the NCAFS. Those who received more parent education using the SENSE program materials demonstrated lower scores (poorer parent‐infant interaction) on the NCAFS. ⁴² It was noted that the NCAFS and other tools that use feeding as the context for the assessment of parent–infant interaction may not be appropriate for measuring parent–infant interaction in the context of the medically complex NICU environment with high‐risk infants with feeding challenges. This could be because some parent–infant interaction behaviours during feeding that are considered favourable later in infancy or childhood, such as face‐to‐face positioning to foster direct eye contact, could be considered intrusive and not appropriate with the high‐risk infant in the NICU. Further, parents may have received education about placing their infant in a sidelying position during feeding, which would result in lower scores for parent interaction.

One study investigated the impact of music on stress reduction in 34 parents (17 in maternity and 17 in the NICU). The SENSE program recommendation for auditory exposure was used with enhanced music intervention comprised of parent psycho‐education, songwriting, music and feeding, music‐assisted relaxation, and playlist creation. NICU parents demonstrated a moderate reduction in stress levels during the music intervention. ⁴³

In addition to identifying implementation outcomes related to parents and medical staff in the NICU, Patel and her team also studied the impact of the SENSE program on feeding outcomes in 110 preterm infants (55 control and 55 treatment) using a prospective quasi‐experimental design with a historical age‐matched control group. Infants who received the SENSE program were observed to have fewer days from first oral feeding to achieving full oral feeding. ³⁵

3.17. Ongoing research

As there is great interest in the SENSE program and it is being implemented worldwide, there is also interest in researching the SENSE program. The SENSE program is being investigated as a doctoral student project in NICUs in Israel and Spain, with the focus of these studies being to investigate implementation and the impact on parent health and infant outcomes. Two other studies, that we are aware of, are currently underway in the USA and are described below.

In a prospective cohort study of 75 very preterm infants born <32 weeks in a level III NICU in Boston, infants are currently being enrolled and are being categorised into two groups: low‐risk without significant injury who receive the SENSE program compared to high‐risk who do have a significant injury and receive the SENSE program in addition to more intensive neuro‐rehabilitative support. The evolution of brain injury and growth is being evaluated every 2 weeks via MRI. These infants will be compared with a reference group of families who decline intervention and who will only receive an MRI at term age. ⁴⁴

Additionally, an NIH‐funded study titled Sensory Optimisation of the Hospital Environment (SOOTHE) is currently enrolling. This study is investigating the SENSE program in a level IV NICU and its affiliated level III satellite NICU in St. Louis, Missouri. Two hundred and fifteen very preterm infants (born <32 weeks estimated gestational age) are being enrolled between the two sites within the first week of life. Once enrolled, infants are randomised to receive either the SENSE program or standard of care during their NICU stay. Outcomes measured in this study include changes in electrocortical activity via amplitude‐integrated electroencephalography (aEEG), neurobehaviour and feeding outcomes at term equivalent age, sensory processing, and neurodevelopmental outcomes through 2 years corrected age, and parent mental health and confidence scores at term through 2 years. ⁴⁵ This work will aid in understanding the efficacy of SENSE programming along with identifying the impact of sensory exposures in the NICU on the developing brain.

4. DISCUSSION

The SENSE program is a new program aimed at optimising the early NICU environment to promote better outcomes for infants and families following high‐risk birth. It is anticipated that it can improve early brain development through positive sensory exposures as well as improve parent participation in the NICU which can have associated impacts on both infant and parents. It is rooted in current evidence, and given that it is relatively new, little research has been published, with only one study on its efficacy. Thus, there is currently a lack of comprehensive data on the effectiveness of the SENSE program. While several studies are currently in progress, much more research is needed to understand the effects of the SENSE program on different infant and family outcomes. Further, understanding mediators of efficacy as well as the generalisability of the effects of the SENSE intervention are important areas for future research. Finally, a better understanding of implementation to ensure the intervention gets to the infants and families it is intended for can enable large‐scale impact.

To our knowledge, only one study on SENSE program efficacy has been conducted. It included many measures of infant neurobehaviour, feeding, sensory outcomes in addition to parent mental health and confidence at term and at 1‐year corrected age. While many of the outcomes were not observed to be impacted by the SENSE program, communication scores at 1‐year corrected age were better in the SENSE group. Due to the complex NICU environment and the impact of multiple confounds on outcomes in the NICU, more research is needed to understand other components of development and function that could be impacted by the SENSE program. Methods and measures that allow more precision in isolating the impact of sensory environments among a population and context with multiple confounds could be useful. In addition, further understanding the immediate effects of early sensory exposures through aEEG in the study supported by NIH may facilitate our understanding of potential mechanisms related to how early exposures impact electrocortical activity.

The original SENSE program was developed for preterm infants who are hospitalised in the NICU. To our knowledge, the program has not been studied and reported in other NICU populations. Another version of the SENSE program, SENSE‐Term, was made available in 2022 and was developed in response to a study investigating the feasibility of SENSE program implementation with infants with hypoxic–ischemic encephalopathy who had undergone hypothermia. The SENSE‐Term program is focused on supporting the sensory needs of infants born full‐term with other medical needs in the NICU, such as surgical, respiratory or neurological needs. A literature review on programming for full‐term infants with cerebral injury was conducted, and the parent education materials were adapted for the full‐term population. The SENSE‐Term program has a static recommendation for daily sensory exposure rather than the doses building across PMA. While the SENSE program could be used with additional NICU populations, more work on reviewing the evidence and supporting the sensory needs of other such populations is warranted, specifically for infants with cardiac needs or neonatal abstinence syndrome. In addition to adapting programming for other populations in the NICU, additional work on building out recommendations across the first year of life could help define appropriate sensory exposures for infants with complex medical needs who have long hospitalisations.

Continued research on the SENSE program is needed to (1) better understand the contribution of each sensory exposure to the outcomes and whether using a multiphasic optimisation strategy might provide insights on decreasing program complexity, (2) understand contextual factors affecting the intervention and its implementation, (3) understand implementation of the SENSE program in a real‐world context and adaptations that are made, (4) understand how sensory exposures under standard of care differ from those received when the SENSE program is implemented, (5) investigate all infant and parent outcomes in relation to SENSE programming, (6) identify mediators of program efficacy, (7) identify patient‐reported outcomes, (8) identify and evaluate adaptations of SENSE programming for different populations, (9) conduct research that aids in filling in the gaps related to appropriate sensory exposures in the NICU, such as ideal light levels during cycling period and if a certain threshold above background noise is needed for auditory exposures, (10) identify whether there are differences in outcome based on different interventions contained in each sensory domain (e.g. kangaroo care compared to holding in arms), and (11) determine if there are differences in outcomes based on who delivers positive sensory exposures in the NICU (parents vs. healthcare professionals or volunteers).

The SENSE program is being used by almost 500 NICUs in the USA and abroad to optimise the early sensory environment and improve outcomes for infants and their families. It can be implemented for a relatively low cost and incorporated into the daily flow of the NICU, with parents receiving support from healthcare professionals in the NICU to provide age‐appropriate, positive sensory exposures to their infants each day of hospitalisation. Adaptations may be needed in the real‐world context. Research thus far is promising, but more research is needed.

AUTHOR CONTRIBUTIONS

Roberta Pineda: Conceptualization; investigation; funding acquisition; writing – original draft; methodology; validation; visualization; writing – review and editing; supervision. Maya Misikoff: Conceptualization; writing – review and editing; validation. Sahar Ghahramani: Conceptualization; validation; writing – review and editing. Joan Smith: Supervision; validation; writing – review and editing. Amit Mathur: Funding acquisition; writing – review and editing; validation; supervision.

FUNDING INFORMATION

This manuscript was not funded. However, an NIH‐funded study is described as part of the manuscript (NICHD RO1 HD105557).

CONFLICT OF INTEREST STATEMENT

Bobbi Pineda and Joan Smith are authors of the SENSE program. The program user fee is charged ‘at cost’, and the authors do not directly benefit financially from the distribution of the program.

Supporting information

Table S1.

Pineda R, Misikoff M, Ghahramani S, Smith J, Mathur A. Description and evidence on the supporting and enhancing neonatal intensive care unit sensory experiences (SENSE) program. Acta Paediatr. 2025;114:731–742. 10.1111/apa.17293