key: cord-266373-8wuvk5cz
authors: Burns, Katherine H.; Saunders, Barbara S.; Burns, Samuel A.
title: Nurturing visual social development in the NICU
date: 2020-09-05
journal: J Perinatol
DOI: 10.1038/s41372-020-00813-w
sha: 
doc_id: 266373
cord_uid: 8wuvk5cz

nan

As hospital systems grapple with containing coronavirus disease (COVID-19) while protecting healthcare providers and patients, developmental considerations of mask usage while caring for infants and young children with prolonged hospitalizations must be considered. We wish to propose developmental interventions to be implemented in NICUs to mitigate the impact of exclusively masked interactions.

It is assumed that infant visual acuity at birth is specifically developed to facilitate facial focus and recognition, contributing to development of "social networks"-a complex set of pathways involving many areas of the developing brain [1] . Although visual input is certainly not the only factor for these networks, denying infants the visual input reinforcing social interactions is not normal and cannot be without risk. We recommend the article Neonatal Transitions in Social Behavior and Their Implications for Autism by Shultz et al. as an excellent review of early social development [2] .

Infants appear to be at very low risk for overall infection, illness, and transmission of COVID-19 [3] . However, infants with prolonged hospitalizations and perinatal complications are known to be at risk for significant neurodevelopmental delays and pathologies supporting the need to carefully nurture the social development of infants in NICUs [4, 5] . There is an urgency in early social development as many of these social milestones scaffold on each other and are typically obtained by 9 months of age, and even newborn infants exhibit distress at unreciprocated interactions [6] . We propose the following for consideration:

(1) Placing higher risk infants in private rooms, especially as discharge approaches and/or the infant is post term.

Development should be a consideration in allocation of private rooms. This allows for social distancing and protection of the highest risk population for COVID-19 in NICUs-adults. (2) Considering infant visualization of adult faces as "therapeutic". It is standard for NICUs to have developmental care plans [7] . In light of COVID-19, extra attention should be paid to social development. This should vary by gestational age with more "passive" protocols for the younger and more fragile infants progressing to more interactive and stimulating protocols. For example, after 2 months corrected age, caregiver-infant interactions should include more mirroring with a greater variety of facial expressions and vocalizations utilized [2, 8] . We do not have data on the exact amounts or frequencies of masked/unmasked interactions necessary to optimize development, but our knowledge of infant development strongly suggests risk. We would, of course, not expect the above accommodations for caregivers with known, active COVID-19 infections, and implementation may vary depending on current community spread. However, active consideration of a more nurturing long-term developmental approach to infants in this critical time of development needs to be undertaken.

Conflict of interest The authors declare that they have no conflict of interest.

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The development of the social brain in human infancy

Neonatal transitions in social behavior and their implications for autism

Systematic review of COVID-19 in children shows milder cases and a better prognosis than adults

Neurodevelopmental outcomes in extremely preterm infants at 2.5 years after active perinatal care in Sweden

Extremely preterm-born infants demonstrate different facial recognition processes at 6-10 months of corrected age

Innate intersubjectivity: newborns; sensitivity to communication disturbance

Individualised developmental care for babies and parents in the NICU: evidence-based best practice guideline recommendations

Early maternal mirroring predicts infant motor system activation during facial expression observation

Newborns' face recognition: role of inner and outer facial features

Visual following and pattern discrimination of face-like stimuli by newborn infants

Face processing at birth: a thatcher illusion study

A Comparison between preterm and fullterm infants' preferences for faces