Family Integrated Care for Preterm Infants in China: A Cluster Randomized Controlled Trial

Human milk feeding for moderate and late preterm infants at age 2 months: Insights from a cluster randomized controlled trial 2-month follow-up

Objective

Human milk (HM) is the optimal nutrition for infants; preterm infants demonstrate shorter HM feeding duration. Care interventions may increase HM feeding among preterm infants after NICU discharge. We compared Alberta Family Integrated Care (FICare) versus Standard Care on HM feeding in preterm infants at age 2 months.

Methods

We conducted a follow-up of a cluster randomized controlled trial of 455 infants and their mothers with data linked to the infant's 2-month public health visit. We used partial proportional odds to model group differences and factors associated with feeding type: exclusive HM (EHM), Non-EHM, or no HM (NHM).

Results

Compared to Standard Care, mothers in Alberta FICare were less likely to provide EHM versus NHM. There was no group difference between EHM and Non-EHM. Mothers with higher education who were on maternity leave or employed were more likely to provide EHM. Infants who received EHM at discharge were more likely to continue at age 2 months. Higher maternal breastfeeding self-efficacy at discharge was associated with a greater likelihood of EHM.

Conclusion

Alberta FICare was not associated with EHM feeding at age 2 months.

Innovation

Different factors predicted the three HM feeding categories, suggesting the need to individualize feeding supports.Trial Registration.ClinicalTrials.gov Identifier NCT02879799, retrospectively registered August 26, 2016.

Maternal separation as early-life stress: Mechanisms of neuropsychiatric disorders and inspiration for neonatal care

The establishment of positive early parent-infant relationships provide essential nourishment and social stimulation for newborns. During the early stages of postnatal brain development, events such as synaptogenesis, neuronal maturation and glial differentiation occur in a highly coordinated manner. Maternal separation, as an early-life stress introducer, can disrupt the formation of parent-child bonds and exert long-term adverse effects throughout life. When offspring are exposed to maternal separation, the body regulates the stress of maternal separation through multiple mechanisms, including neuroinflammatory responses, neuroendocrinology, and neuronal electrical activity. In adulthood, early maternal separation has long-term effects, such as the induction of neuropsychiatric disorders such as anxiety, depression, and cognitive dysfunction. This review summarized the application of maternal separation models and the mechanisms of stress system response in neuropsychiatric disorders, serving as both a reminder and inspiration for approaches to improve neonatal care, "from bench to bedside".

Validation of a Costing Algorithm and Cost Drivers for Neonates Admitted to the Neonatal Intensive Care Unit

OBJECTIVE

 Neonatal intensive care units (NICUs) account for over 35% of pediatric in-hospital costs. A better understanding of NICU expenditures may help identify areas of improvements. This study aimed to validate the Canadian Neonatal Network (CNN) costing algorithm for seven case-mix groups with actual costs incurred in a tertiary NICU and explore drivers of cost.

STUDY DESIGN

 A retrospective cohort study of infants admitted within 24 hours of birth to a Level-3 NICU from 2016 to 2019. Patient data and predicted costs were obtained from the CNN database and were compared to actual obtained from the hospital accounting system (Coût par Parcours de Soins et de Services). Cost estimates (adjusted to 2017 Canadian Dollars) were compared using Spearman correlation coefficient (rho).

RESULTS

 Among 1,795 infants included, 169 (9%) had major congenital anomalies, 164 (9%) with <29 weeks' gestational age (GA), 189 (11%) with 29 to 32 weeks' GA, and 452 (25%) with 33 to 36 weeks' GA. The rest were term infants: 86 (5%) with hypoxic-ischemic encephalopathy treated with therapeutic hypothermia, 194 (11%) requiring respiratory support, and 541 (30%) admitted for other reasons. Median total NICU costs varied from $6,267 (term infants admitted for other reasons) to $211,103 (infants born with <29 weeks' GA). Median daily costs ranged from $1,613 to $2,238. Predicted costs correlated with actual costs across all case-mix groups (rho range 0.78-0.98, p < 0.01) with physician and nursing representing the largest proportion of total costs (65-82%).

CONCLUSION

 The CNN algorithm accurately predicts NICU total costs for seven case-mix groups. Personnel costs account for three-fourths of in-hospital total costs of all infants in the NICU.

KEY POINTS

· Very preterm infants born below 33 weeks of gestation account for most of NICU resource use.. · Human resources providing direct patient care represented the largest portion of costs.. · The algorithm strongly predicted total costs for all case-mix groups..

Analyzing the Responses of Enteric Bacteria to Neonatal Intensive Care Supplements

In the neonatal intensive care unit, adequate nutrition requires various enteral products, including human milk and formula. Human milk is typically fortified to meet increased calorie goals, and infants commonly receive vitamin mixes, iron supplements, and less frequently, thickening agents. We examined the growth of 16 commensal microbes and 10 pathobionts found in the premature infant gut and found that formula, freshly pasteurized milk, and donated banked milk generally increased bacterial growth. Fortification of human milk significantly elevated the growth of all microbes. Supplementation with thickeners or NaCl in general did not stimulate additional growth. Vitamin mix promoted the growth of several commensals, while iron promoted growth of pathobionts. These data indicate that pathobionts in the preterm gut have significant growth advantage with preterm formula, fortified donor milk, and supplemented iron and suggest that the choice of milk and supplements may impact the infant gut microbiota.

Impact of restricted family presence during the COVID-19 pandemic on critically ill patients, families, and critical care clinicians: a qualitative systematic review

BACKGROUND

We aimed to synthesize the qualitative evidence on the impacts of COVID-19-related restricted family presence policies from the perspective of patients, families, and healthcare professionals from neonatal (NICU), pediatric (PICU), or adult ICUs.

METHODS

We searched MEDLINE, EMBASE, Cochrane Databases of Reviews and Clinical Trials, CINAHL, Scopus, PsycINFO, and Web of Science. Two researchers independently reviewed titles/abstracts and full-text articles for inclusion. Thematic analysis was completed following appraising article quality and assessing confidence in the individual review findings using standardized tools.

RESULTS

We synthesized 54 findings from 184 studies, revealing the impacts of these policies in children and adults on: (1) Family integrated care and patient and family-centered care (e.g., disruption to breastfeeding/kangaroo care, dehumanizing of patients); (2) Patients, families, and healthcare professionals (e.g., negative mental health consequences, moral distress); (3) Support systems (e.g., loss of support from friends/families); and (4) Relationships (e.g., loss of essential bonding with infant, struggle to develop trust). Strategies to mitigate these impacts are reported.

CONCLUSION

This review highlights the multifaceted impacts of restricted visitation policies across distinct care settings and strategies to mitigate the harmful effects of these policies and guide the creation of compassionate family presence policies in future health crises.

REGISTRATION

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=290263 .

Facilitators and constraints to family integrated care in low-resource settings informed the adaptation in Uganda

AIM

Family Integrated Care (FICare) was developed in high-income countries and has not been tested in resource-poor settings. We aimed to identify the facilitators and constraints that informed the adaptation of FICare to a neonatal hospital unit in Uganda.

METHODS

Maternal focus groups and healthcare provider interviews were conducted at Uganda's Jinja Regional Referral Hospital in 2020. Transcripts were analysed using inductive content analysis. An adaptation team developed Uganda FICare based on the identified facilitators and constraints.

RESULTS

Participants included 10 mothers (median age 28 years) and eight healthcare providers (seven female, median age 41 years). Reducing healthcare provider workload, improving neonatal outcomes and empowering mothers were identified as facilitators. Maternal stress, maternal difficulties in learning new skills and mistrust of mothers by healthcare providers were cited as constraints. Uganda FICare focused on task-shifting important but neglected patient care tasks from healthcare providers to mothers. Healthcare providers learned how to respond to maternal concerns. Intervention material was adapted to prioritise images over text. Mothers familiar with FICare provided peer-to-peer support to other mothers.

CONCLUSION

Uganda FICare shares the core values of FICare but was adapted to be feasible in low-resource settings.

The effect of family integrated care on preparing parents with premature infants hospitalized in the neonatal intensive care unit for discharge

OBJECTIVE

The study was designed as a randomized controlled experimental trial to determine the effect of the Family Integrated Care (FICare) model on the readiness of parents whose infants were hospitalized in the neonatal intensive care unit (NICU) for discharge and home care of the infants.

STUDY DESIGN

Parents in the intervention group received FICare, and parents in the control group received standard care.

RESULTS

The total mean score of the mothers and fathers in the intervention group regarding readiness for discharge and home care was higher than that of the control group, and a significant difference was observed. A statistically significant difference was found in terms of discharge weight, the day of first enteral feeding, and first breast milk.

CONCLUSION

The FICare model was observed to enhance the readiness of mothers and fathers for discharge and home care and positively affect the infant's weight gain, the status of breastfeeding and the continuation of nutrition.

CLINICAL TRIAL REGISTRATION

Registered on ClinicalTrials.gov (Identifiers: NCT04478162 Unique Protocol ID: 16214662/050.01.04/14) on 17/07/2020.

Perceptions of families and healthcare providers about feeding preterm infants in the neonatal intensive care unit: protocol for a qualitative systematic review

INTRODUCTION

The underdevelopment of preterm infants can lead to delayed progression through key early milestones. Demonstration of safe oral feeding skills, constituting proper suck-swallow reflex are requirements for discharge from the neonatal intensive care unit (NICU) to ensure adequate nutrition acquisition. Helping an infant develop these skills can be draining and emotional for both families and healthcare staff involved in the care of preterm infants with feeding difficulties. Currently, there are no systematic reviews evaluating both family and healthcare team perspectives on aspects of oral feeding. Thus, we first aim to evaluate the current knowledge surrounding the perceptions, experiences and needs of families with preterm babies in the context of oral feeding in the NICU. Second, we aim to evaluate the current knowledge surrounding the perceptions, experiences and needs of healthcare providers (physicians, advanced practice providers, nurses, dietitians, speech-language pathologists and occupational therapists) in the context of oral feeding in the NICU.

METHODS AND ANALYSIS

A literature search will be conducted in multiple electronic databases from their inception, including PubMed, CINHAL, Embase, the Cochrane Central Register for Controlled Trials and PsycINFO. No restrictions will be applied based on language or data of publication. Two authors will screen the titles and abstracts and then review the full text for the studies' inclusion in the review. The data will be extracted into a pilot-tested data collection sheet by three independent authors. To evaluate the quality, reliability and relevance of the included studies, the Critical Appraisal Skills Programme checklist will be used. The overall evidence will be assessed using the Grading of Recommendation Assessment, Development and Evaluation criteria. We will report the results of the systematic review by following the Enhancing Transparency in Reporting the synthesis of Qualitative research checklist.

ETHICS AND DISSEMINATION

Ethical approval of this project is not required as this is a systematic review using published and publicly available data and will not involve contact with human subjects. Findings will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42023479288.

Short and mid-term neonatal outcomes in high-risk infants undergoing FICare: a case control study

BACKGROUND

FICare model has been evaluated mostly on the stable preterm infant.We have scaled the model to two implementation levels(basic/advanced),making it suitable for all high-risk neonates.We report on the short- and mid-term outcomes of infants enrolled in a pilot on FICare implementation at our NICU.

METHODS

During 52 months study period,families were invited to join the program if their newborns' admission required neonatal specialized care for at least 3 weeks,and trained according to the program's curricula.Following a rigorous sequential admission order,each case(FICare group:134 < 34 weeks;52 term newborns)was matched by a contemporary control(CC:134 < 34 weeks;52 term newborns)and 2 historical controls born within the 3 years prior to FICare site implementation(HC:268 < 34 weeks;104 term newborns),cared as usual RESULTS: FICare intervention started by the end of first week of postnatal life.Rates of breastfeeding during admission and at discharge,and direct breastfeeding upon discharge were higher in FICare compared to CC and HC.Duration of intermediate care hospitalization(preterm and term cohorts)and total hospital length of stay (term cohorts)were shorter in FICare group.Use of Emergency Services after discharge was also lower in the FICare group CONCLUSIONS: Short and mid-term efficacy of FICare on health outcomes and family empowerment in a broader and highly-vulnerable neonatal population supports its generalization in complex healthcare neonatal services.

IMPACT STATEMENT

Scaling the FICare model to the critically ill, unstable premature and term infant is feasible and safe. The early intervention shows similar benefits in the short- and mid-term infants' outcomes in the whole spectrum of neonatal specialized care.

Identifying outcomes and outcome measures in neonatal family-centered care trials: a systematic review

BACKGROUND

A wide range of outcomes for infants and parents has been reported in clinical trials testing FCC interventions. This systematic review aimed to identify outcomes, outcome measures, and time-points reported in experimental studies testing FCC interventions in neonatal care units.

METHODS

This review included experimental studies investigating FCC interventions in neonatal settings. Database searches were conducted in MEDLINE, EMBASE, CINAHL, Cochrane, PsycINFO, Scopus, JBI, Lilacs, and SciELO, completed in December 2022 and updated in November 2023. Critical appraisal was performed using the JBI checklist for randomized controlled trials, and a narrative synthesis process was used. Outcomes were categorized into the Comet Taxonomy core areas.

RESULTS

The search identified 8787 papers; 42 studies were included in the analysis. Totally, 60 outcomes were identified: 42 infant and 18 parents' outcomes. Outcomes were clustered into 12 domains for infants and five domains for parents and measured by 97 outcome measures. The included studies reported 25 and 27 different time-points for infants and parents, respectively.

CONCLUSION

This review of studies testing FCC interventions identified heterogeneity and inconsistency of outcomes, outcome measures, and time-points measuring the outcomes. Developing a core outcome set for FCC studies is warranted to benchmark the evidence and identify best-practices.

IMPACT

This systematic review identified inconsistency of outcomes, outcome measures, and time-points reported in quantitative studies testing family-centered care interventions in neonatal care settings. The lack of standardized outcomes and outcome measures reported in clinical trials makes it difficult to synthesize data to provide conclusive recommendations. This systematic review will contribute to the development of a core outcome set for research testing family-centered care interventions in neonatal care settings.

Impact of discharge criteria on the length of stay in preterm infants: A retrospective study in Japan and Finland

BACKGROUND

To shorten the hospital stay in preterm infants, it is important to understand the factors extending the length of stay.

AIMS

To understand how different discharge criteria affect the length of stay in preterm infants.

STUDY DESIGN

A retrospective comparison study.

SUBJECTS

Preterm infants born at 28 to 31 gestational weeks in 2020-2021 in a Level IV NICU in Japan (n = 22) and a Level III NICU in Finland (n = 49).

OUTCOME MEASURES

We compared the most common last discharge criteria and the postmenstrual age (PMA) between the two NICUs. The potential extending effects of each discharge criterion on the length of stay were also evaluated. The discharge criteria were classified into six categories: temperature, respiration, feeding, examination, weight limit, and family readiness.

RESULTS

The PMA at discharge was significantly higher in Japan than in Finland: median 40.7 (interquartile range 39.9-41.3) vs. 37.9 (36.9-39.0) weeks; r = 0.58; p < 0.001. The most common last discharge criterion was the family criterion in Japan (n = 19; 86 %) and the respiration criterion in Finland (n = 43; 88 %). In Japan, the length of stay was extended by 7.9 (standard deviation [SD] 7.0) days due to a lack of family readiness for discharge and 8.7 (SD 8.7) days due to not having discharged home with a feeding tube as a common practice.

CONCLUSIONS

The length of stay of preterm infants in Japan could be notably reduced by supporting the parents' earlier readiness for discharge and allowing tube feeding at home.

Family integrated care: State of art and future perspectives

Family integrated care (FICare) represents a contemporary approach to health care that involves the active participation of families within the healthcare team. It empowers families to acquire knowledge about the specialised care required for their newborns admitted to neonatal intensive care unit (NICU) and positions them as primary caregivers. Healthcare professionals in this model act as mentors and facilitators during the hospitalisation period. This innovative model has exhibited notable enhancements in both short- and long-term health outcomes for neonates, alongside improved psychological well-being for families and heightened satisfaction among healthcare professionals. Initially designed for stable premature infants and their families, FICare has evolved to include critically ill premature and full-term infants. Findings from recent studies affirm the safety and feasibility of FICare as a NICU-wide model of care, benefiting all infants and families. The envisioned expansion of FICare focusses on sustainability and extending its implementation, recognising the necessity for tailored adaptations to suit varying diverse cultural and socio-economic contexts.

RISEinFAMILY project: the integration of families at neonatal intensive care units (NICUs) to empower them as primary caregivers: study protocol for a stepped wedge cluster controlled trial

BACKGROUND

Family Integrated Care (FICare) has demonstrated positive outcomes for sick neonates and has alleviated the psychological burden faced by families. FICare involves structured training for professionals and caregivers along with the provision of resources to offer physical and psychological support to parents. However, FICare implementation has been primarily limited to developed countries. It remains crucial to assess the scalability of this model in overcoming social-cultural barriers and conduct a cost-effectiveness analysis. The RISEinFAMILY project aims to develop an adapted FICare model that can serve as the international standard for neonatal care, accommodating various cultural, architectural, and socio-economic contexts.

METHODS

RISEinFAMILY is a pluri-cultural, stepped wedge cluster controlled trial conducted in Spain, Netherlands, the UK, Romania, Turkey, and Zambia. Eligible participants include infant-family dyads admitted to the Neonatal Intensive Care Unit (NICU) requiring specialised neonatal care for a minimum expected duration of 7 days, provided there are no comprehension barriers. Notably, this study will incorporate a value of implementation analysis on FICare, which can inform policy decisions regarding investment in implementation activities, even in situations with diverse data.

DISCUSSION

This study aims to evaluate the scalability and adaptation of FICare across a broader range of geographical and sociocultural contexts and address its sustainability. Furthermore, it seeks to compare the RISEinFAMILY model with standard care, examining differences in short-term newborn outcomes, family mental health, and professional satisfaction.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06087666. Registered on 17 October 2023.

PROTOCOL VERSION

19 December 2022; version 2.2.

Benefits and Challenges of Implementing an Adaptation of Family Integrated Care in a Ugandan Setting

BACKGROUND

Family Integrated Care (FICare) integrates parents as partners in neonatal intensive care unit care. Our team adapted and implemented this approach in a Ugandan unit for hospitalized neonates.

PURPOSE

This qualitative descriptive study examined the perceptions of mothers and healthcare professionals (HCPs) of the benefits and challenges of this new approach to care.

METHODS

Fifty-one mothers of hospitalized neonates born weighing greater than 2000 g participated in the program. They were taught to assess neonate danger signs, feeding, and weight. After discharge, a subsample (n = 15) participated in focus groups to explore benefits and challenges of their participation in care. Interviews with 8 HCPs were also conducted for the same purpose. Transcripts from focus groups and interviews were analyzed using inductive content analysis to describe the benefits and challenges from the perspectives of mothers and HCPs.

RESULTS

For mothers a benefit was decreased stress. Both mothers and HCPs reported that the knowledge and skills mothers acquired were a benefit as was their ability to apply these to the care of their neonate. Improved relations between mothers and HCPs were described, characterized by greater exchange of information and HCPs' attentiveness to mothers' assessments. Mothers felt ready for discharge and used their knowledge at home. HCPs noted a decrease in their workload. Challenges included the need for mothers to overcome fears about performing the tasks, their own well-being and literacy skills, and access to equipment.

IMPLICATIONS FOR PRACTICE

Mothers' participation in their neonates' care can have benefits for them and their neonate.

Family Management Skills Reported by Parents of Preterm Infants in the NICU Using the Self- and Family Management Framework (SFMF)

BACKGROUND

Across the globe, family-integrated care (FICare) has become an evidence-based standard in which parents deliver the majority of infant care in the neonatal intensive care unit (NICU). Because of extensive barriers to parent presence, adaptations to FICare may be required for successful implementation. Family management theory may provide structure to the Parent Education of FICare and help nurses guide parents' skill development as equal care members.

PURPOSE

To identify family management skills employed by NICU parents using the Self- and Family Management Framework (SFMF).

METHODS

We conducted secondary analyses of qualitative interview data from NICU parents (n = 17) who shared their experiences of using family management skills to care for their infant. We categorized skills according to 3 main self- and family management processes: Focusing on Infant Illness Needs; Activating Resources; and Living With Infant Illness.

RESULTS

Parents reported several family management skills currently identified in the SFMF, as well as new skills such as conflict management, power brokerage, and addressing resources related to social determinants of health. Parent activation of resources was critical to sustaining parent focus on the infant's illness needs.

IMPLICATIONS FOR PRACTICE AND RESEARCH

By teaching skills that parents reported as helping them manage infant care, neonatal nurses may better facilitate parent integration into the care team. Future researchers can incorporate the skills identified in this study into the design of family management interventions that facilitate FICare implementation in the United States.

Effect of family integrated care on stress in mothers of preterm infants: A multicenter cluster randomized controlled trial

BACKGROUND

Reducing mother-infant separation in early life is a key breakthrough in the care improvement model in the neonatal intensive care unit (NICU). Previously, we reported effect of family integrated care (FICare) on clinical outcomes of preterm infants. We further clarify effect of FICare on maternal stress.

METHODS

Mothers of preterm infants at eleven NICUs were randomized to the FICare group and the control group. The primary outcome was the reduction in Parental Stress Scale: NICU (PSS:NICU) score from enrollment to discharge.

RESULTS

Total of 601 mothers (298 in FICare and 303 in control groups) enrolled. There was no significant difference in PSS:NICU score between the 2 groups at enrollment (P = 0.824), and the FICare group had lower scores at discharge (P < 0.001). PSS:NICU scores of both groups were significantly decreased at discharge compared to at enrollment (P < 0.001), and the reduction was greater in the FICare group (P < 0.001). After applying linear regressions to adjust for potential confounders, results remained unchanged (adjusted P < 0.001). PSS:NICU score reductions from enrollment to discharge were positively correlated with maternal age in the control group (ρ = 0.147, P = 0.011).

LIMITATIONS

This study was limited to post-hoc analyses and did not include follow-up to evaluate long-term effects.

CONCLUSIONS

FICare is helpful for reducing maternal stress in preterm infants in the NICU. Older mothers tend to have limited improvements in stress after traditional nonparent care, which suggests that they may benefit more from the FICare model.

[Preventive early intervention strategies for neurodevelopmental disorders of high-risk infants]

Neurodevelopmental disorders in children have become a significant global public health concern, impacting child health worldwide. In China, the current intervention model for high-risk infants involves early diagnosis and early treatment. However, in recent years, overseas studies have explored novel preventive early intervention strategies for neurodevelopmental disorders in high-risk infants, achieving promising results. This article provides a comprehensive review of the optimal timing, methods, and intervention models of the preventive early intervention strategies for neurodevelopmental disorders in high-risk infants. The aim is to enhance the awareness and knowledge of healthcare professionals regarding preventive early intervention strategies for neurodevelopmental disorders in high-risk infants, facilitate clinical research and application of such interventions in China, and ultimately reduce the incidence of neurodevelopmental disorders in this high-risk population.

Monitoring the Use of Human Milk, the Ideal Food for Very Low-Birth-Weight Infants-A Narrative Review

Aware of the utmost importance of feeding premature babies-especially those of lower weight-with human milk, as well as the need to monitor this important element of neonatal care, we focused on four aspects in this review. First of all, we reviewed the beneficial effects of feeding premature infants with breast milk in the short and long term. Secondly, we performed a quantitative evaluation of the rates of breastfeeding and feeding with human milk in Very-Low-Birth-Weight infants (VLBWs) during hospitalization in the Neonatal Intensive Care Unit (NICU) and at discharge. Our aim was to take a snapshot of the current status of human milk-feeding care and track its trends over time. Then we analyzed, on the one hand, factors that have been proven to facilitate the use of maternal milk and, on the other hand, the risk factors of not feeding with breast milk. We also considered the spread of human milk banking so as to assess the availability of donated milk for the most vulnerable category of premature babies. Finally, we proposed a protocol designed as a tool for the systematic monitoring of actions that could be planned and implemented in NICUs in order to achieve the goal of feeding even more VLBWs with human milk.

Close Collaboration with Parents Affects the Length of Stay and Growth in Preterm Infants: A Register-Based Study in Finland

INTRODUCTION

This study aimed to evaluate how Close Collaboration with Parents (CC), a neonatal intensive care unit (NICU)-wide educational model for healthcare staff to improve their family-centred care practices, affects the length of stay (LOS), growth, and later hospital visits and rehospitalizations of preterm infants.

METHODS

This register-based study included all preterm infants born below 35 weeks of gestation in Finland from 2006 to 2020. Eligible infants were classified into the Full Close Collaboration (Full-CC) group (n = 2,104) if the NICUs of both the delivery and discharge hospitals had implemented the intervention; into the Partial-CC group (n = 515) if only one of the NICUs had implemented the intervention; and into the control group (n = 11,621) if neither had implemented the intervention.

RESULTS

The adjusted LOS, the primary outcome, was 1.8 days or 6% shorter in the Full-CC group than in the control group (geometric mean ratio 0.94, 95% confidence interval [95% CI] 0.89-1.00). Growth was better in the Full-CC group compared to the control group: adjusted group difference 11.7 g/week (95% CI, 1.4-22.0) for weight, 1.3 mm/week (95% CI, 0.6-2.0) for length. The Full-CC group infants had lower odds of having any unscheduled outpatient visits compared to the control group (adjusted odds ratio 0.81; 95% CI, 0.67-0.98). No significant differences were found in any other comparisons.

DISCUSSION/CONCLUSION

The unit-wide intervention improving family-centred care practices in NICUs may lead to more efficient use of hospital resources by shortening the LOS, improving growth, and decreasing hospital visits of preterm infants.

Impact of On-the-Job Training on Nurses' Performance in Creating a Healing Environment and Clustered Nursing Care for Premature

Introduction

Premature infants require specialized care, and nurses need to have specific skills and knowledge to provide this care effectively.

Objective

To evaluate the impact of an on-the-job training program on the improvement of nurses' knowledge and practice related to creation of a healing environment and clustering nursing procedures.

Methods

From January to April 2022, a study utilizing a one-group pre- and post-test design was conducted at NICUs in governmental hospitals. The study participants involved 80 nurses working in these NICUs. Researchers used predesigned questionnaire and checklist practice to collect the data pre and post the intervention.

Results

37.5% of the participants were aged between 25 and less than 30 years, with a mean age of 28.99 ± 7.43 years. Additionally, 73.7% of the nurses were female, with a mean experience of 9.45 ± 3.87 years. Prior to the intervention, the study found that a majority of the nurses (62.4%) demonstrated poor knowledge. However, after the intervention, a significant improvement was observed, with 60.0% of the nurses demonstrated good knowledge. Likewise, prior to the intervention, the study revealed that the majority of the nurses (83.8%) exhibited incompetent practice. However, post-intervention, a substantial improvement was observed, with 81.3% of the nurses demonstrated competent practice.

Conclusion

On-the-job training had significant improvements in nurses' knowledge and practices regarding applying healing environments and clustering nursing care. On-the-job training is suggested as an adaptable, effective and low-cost technique to train nurses. To maintain the improvement achieved, ongoing instruction, feedback, assessment/reassessment, and monitoring are encouraged.

Impact of a family-centred clinical care programme on short-term outcomes of very low-birth weight infants

AIM

We evaluated the effects of a family-centred clinical care pathway and case management programme on short-term clinical outcome in a cohort of very low-birth weight (VLBW) infants.

METHODS

The programme, named NeoPAss, was developed at the Department of Neonatology Children's hospital Passau in 2013. Short-term outcomes of infants were compared to matched controls from the Bavarian neonatology surveillance database before (n = 111; 2008-2012) and after implementation (n = 170; 2014-2017).

RESULTS

After implementation the rate of late-onset sepsis was significantly lower (2.5% vs. 10.7%, p = 0.005) and the length of stay was significantly shorter (VLBW 28 to 31 weeks' gestational age (GA) 47.5 vs. 53.1 days, p = 0.047; <28 weeks' GA 79.4 vs. 91.9 days, p = 0.007) in the intervention group compared to controls. Infants were discharged with significantly lower weight (mean 2351 vs. 2539 g, p = 0.013). There was no statistically significant difference in the rate of intraventricular haemorrhage (3.7% vs. 8.2%), necrotizing enterocolitis (0.6% vs. 1.9%) and bronchopulmonary dysplasia (0% vs. 6.9%).

CONCLUSION

Our data confirm that of other studies demonstrating a beneficial effect of family-centred care programmes and provides evidence that structured parental involvement is not associated with increased risk of infection in a VLBW cohort.

Effect of family integrated care on breastfeeding of preterm infants: A scoping review

AIMS

The aims are to describe the key components of family integrated care intervention for preterm infants in the neonatal intensive care unit (NICU) and assess the impact on breastfeeding outcomes for those infants.

DESIGN

A scoping review.

METHODS

We conducted a systematic study search based on the databases, including PubMed, Scopus, Cochrane, Web of Science, MEDLINE, CINAHL, CNKI and Wanfang Database in December 2022. The search time ranged from database establishment to 31 December 2022. Papers by manual searching were also listed on the references. We adopted Joanna Briggs Institute Reviewer's Manual methodology and followed the PRISMA guidelines for Scoping Reviews (PRISMA-ScR) to conduct the review. Two independent reviewers filtered the papers, extracted data and synthesized the findings. A table was used to extract data and synthesize results.

RESULTS

After systematic searching, 11 articles that implemented family integrated care (FIcare) were finally included in this scoping review. By analysing the implementation of this nursing model, we identified seven main components: NICU staff training, parent education, parent participation in infants' care, parent involvement in medical plans, peer support, NICU environmental support and mobile app for parents. Based on the extracted breastfeeding data, this scoping review concludes that family integrated care shows a positive effect on increasing breastfeeding rates at discharge. Through this scoping review, we find that family integrated care is feasible and it can support breastfeeding of preterm infants. Further studies will be needed to provide more evidence that family integrated care could facilitate breastfeeding of preterm infants.

IMPACT

This scoping review provides evidence for the positive role of family integrated care on breastfeeding outcomes. The analysis may contribute to the implementation of family integrated care.

NO PATIENT OR PUBLIC CONTRIBUTION

No further public or patient contribution was made in view of the review-based nature of the research.

Collaborating to Improve Neonatal Care: ParentAl Participation on the NEonatal Ward-Study Protocol of the neoPARTNER Study

Parents are often appointed a passive role in the care for their hospitalised child. In the family-integrated care (FICare) model, parental involvement in neonatal care is emulated. Parental participation in medical rounds, or family-centred rounds (FCR), forms a key element. A paucity remains of randomised trials assessing the outcomes of FCR (embedded in FICare) in families and neonates, and outcomes on an organisational level are relatively unexplored. Likewise, biological mechanisms through which a potential effect may be exerted are lacking robust evidence. Ten level two Dutch neonatal wards are involved in this stepped-wedge cluster-randomised trial FCR (embedded in FICare) by one common implementation strategy. Parents of infants hospitalised for at least 7 days are eligible for inclusion. The primary outcome is parental stress (PSS:NICU) at discharge. Secondary outcomes include parental, neonatal, healthcare professional and organisational outcomes. Biomarkers of stress will be analysed in parent-infant dyads. With a practical approach and broad outcome set, this study aims to obtain evidence on the possible (mechanistic) effect of FCR (as part of FICare) on parents, infants, healthcare professionals and organisations. The practical approach provides (experiences of) FICare material adjusted to the Dutch setting, available for other hospitals after the study.

A Pilot Study of Family-Integrated Care (FICare) in Critically Ill Preterm and Term Infants in the NICU: FICare Plus

Family-integrated care (FICare) is associated with improved developmental outcomes and decreased parental mental health risks in stable preterm infants. However, less is known about its application in critically ill infants who are at greater risk for adverse outcomes. The objective of this study was to assess the safety and feasibility of implementation of an augmented FICare program, FICare Plus, in critically ill infants in the first few weeks of life. Resources were specifically developed for staff and parents to support earlier parental engagement in infant care. Infant health outcomes and standardized measures of parental stress, anxiety and parenting self-efficacy were also collected using standardized questionnaires: State -Trait Anxiety Inventory (STAI), Parental Stressor Scale: NICU (PSS: NICU), Perceived Parenting Self-Efficacy Tool and Family Centered Care Survey. The t-test or Wilcoxon rank-sum test were used to compare continuous variables, while the Chi-square or Fisher exact test were used for categorical variables, respectively. In this prospective cohort study, 41 critically ill infants were enrolled: 17 in standard care (SC) and 24 in the FICare Plus group. The tools and procedures developed for FICare Plus successfully supported greater engagement in the care of their infants with no increase in adverse events and no increase in parental stress. Parents in the FICare Plus cohort felt confident to participate in their infant's care. The staff also found this model of care acceptable and well adopted. Preliminary measures of infant efficacy were similar in both groups. Total anxiety scores were high among all parents at enrollment (87 (67-94) vs. 70.5 (66-86); p-value 0.22). However, the scores prior to discharge were lower in FICare Plus group (78 (71-90) vs. 63 (52-74.5); p-value 0.02). This pilot study showed that it is feasible and safe to implement family-integrated care in critically ill infants.

The Pediatrician Workforce in the United States and China

From 2019 to 2022, the For Our Children project gathered a team of Chinese and American pediatricians to explore the readiness of the pediatric workforce in each country to address pressing child health concerns. The teams compared existing data on child health outcomes, the pediatric workforce, and education and combined qualitative and quantitative comparisons centered on themes of effective health care delivery outlined in the World Health Organization Workforce 2030 Report. This article describes key findings about pediatric workload, career satisfaction, and systems to assure competency. We discuss pediatrician accessibility, including geographic distribution, practice locations, trends in pediatric hospitalizations, and payment mechanisms. Pediatric roles differed in the context of each country's child health systems and varied teams. We identified strengths we could learn from one another, such as the US Medical Home Model with continuity of care and robust numbers of skilled clinicians working alongside pediatricians, as well as China's Maternal Child Health system with broad community accessibility and health workers who provide preventive care.In both countries, notable inequities in child health outcomes, evolving epidemiology, and increasing complexity of care require new approaches to the pediatric workforce and education. Although child health systems in the United States and China have significant differences, in both countries, a way forward is to develop a more inclusive and broad view of the child health team to provide truly integrated care that reaches every child. Training competencies must evolve with changing epidemiology as well as changing health system structures and pediatrician roles.

Effect of Family Integrated Care on maternal stress in preterm infants in the Neonatal Intensive Care Unit: A bi-center experience

AIM

To compare the effect of family integrated care (FICare) on maternal stress in preterm infants with traditional non-parent neonatal intensive care unit (NICU) care.

METHODS

We continuously enrolled mothers and their preterm infants from two NICUs between August 2014 and April 2017; while one NICU applied the FICare model (FICare group) and the other performed standard non-parent care model (control group). Maternal stress was evaluated by the Parental Stress Scale: NICU (PSS: NICU) on admission and right before the discharge. A generalized linear model to adjust for potential confounders. Subgroup analysis was also performed for comparisons between two groups.

RESULTS

A total of 215 mothers with preterm infants were included in this study, among whom 118 (54.88%) were in FICare group and 97 (45.12%) were in control group. The mean PSS: NICU score was 117.36 ± 26.27 on admission with no difference between two groups. Before being discharged home, the PSS: NICU score of parents in both groups was significantly reduced, with the score of FICare group was significantly lower than that of control group. In all sub-domains of PSS: NICU score as sights and sounds, baby looks and behavior score, and parental role, the scores of FICare group were significantly lower than control group.

CONCLUSIONS

There was a simultaneous decrease of maternal stress for NICU preterm infants. FICare further facilitates reducing the maternal stress. It shall be encouraged to apply FICare model in NICUs.

Family Integrated Care in Uganda: a feasibility study

OBJECTIVE

To determine the feasibility of adapting Family Integrated Care to a neonatal hospital unit in a low-income country.

DESIGN

Single-centre, pre/post-pilot study of an adapted Family Integrated Care programme in Uganda (UFICare).

SETTING

Special Care Nursery at a Ugandan hospital.

PATIENTS

Singleton, inborn neonates with birth weight ≥2 kg.

INTERVENTIONS

As part of UFICare, mothers weighed their infant daily, assessed for severe illness ('danger signs') twice daily and tracked feeds.

MAIN OUTCOME MEASURES

Feasibility outcomes included maternal proficiency and completion of monitoring tasks. Secondary outcomes included maternal stress, discharge readiness and post-discharge healthcare seeking.

RESULTS

Fifty-three mother-infant dyads and 51 mother-infant dyads were included in the baseline and intervention groups, respectively. Most mothers were proficient in the tasks 2-4 days after training (weigh 43 of 51; assess danger signs 49 of 51; track feeds 49 of 51). Mothers documented their danger sign assessments 82% (IQR 71-100) of the expected times and documented feeds 83% (IQR 71-100) of hospital days. In the baseline group, nurses weighed babies 29% (IQR 18-50) of hospitalised days, while UFICare mothers weighed their babies 71% (IQR 57-80) of hospitalised days (p<0.001). UFICare mothers had higher Readiness for Discharge scores compared with the baseline group (baseline 6.8; UFICare 7.9; p<0.001). There was no difference in maternal stress scores or post-discharge healthcare seeking.

CONCLUSIONS

Ugandan mothers can collaborate in the medical care of their hospitalised infant. By performing tasks identified as important for infant care, mothers felt more prepared to care for their infant at discharge.

Survey on human milk feeding and enteral feeding practices for very-low-birth-weight infants in NICUs in China Neonatal Network

BACKGROUND

The breastfeeding rate in China is lower than that in many other countries and the extent of adoption of the "Feeding Recommendations for Preterm Infants and Low Birth Weight Infants" guideline in NICUs remains unclear.

METHOD

A web-based survey about the current status of human milk feeding and enteral feeding practices at NICUs was sent to all China Neonatal Network's cooperation units on September 7, 2021, and the respondents were given a month to send their responses.

RESULTS

All sixty NICUs responded to the survey, the reply rate was 100%. All units encouraged breastfeeding and provided regular breastfeeding education. Thirty-six units (60.0%) had a dedicated breastfeeding/pumping room, 55 (91.7%) provided kangaroo care, 20 (33.3%) had family rooms, and 33 (55.0%) routinely provided family integrated care. Twenty hospitals (33.3%) had their own human milk banks, and only 13 (21.7%) used donor human milk. Eight units (13.3%) did not have written standard nutrition management guidelines for infants with body weight < 1500 g. Most units initiated minimal enteral nutrition with mother's milk for infants with birth weight ˂1500 g within 24 h after birth. Fifty NICUs (83.3%) increased the volume of enteral feeding at 10-20 ml/kg daily. Thirty-one NICUs (51.7%) assessed gastric residual content before every feeding session. Forty-one NICUs (68.3%) did not change the course of enteral nutrition management during drug treatment for patent ductus arteriosus, and 29 NICUs (48.3%) instated NPO for 1 or 2 feeds during blood transfusion.

CONCLUSION

There were significant differences in human milk feeding and enteral feeding strategies between the NICUs in CHNN, but also similarities. The data obtained would be useful in the establishment of national enteral feeding guidelines for preterm infants and quality improvement of cooperation at the national level.

Clinical practice guideline for kangaroo mother care in preterm and low birth weight infants

Kangaroo mother care has reduced mortality and morbidity in preterm and low birth weight infants and has many benefits, such as promoting breastfeeding. Based on the current evidence in China and international, we developed a clinical practice guideline for kangaroo mother care in preterm and low birth weight infants using the Grading of Recommendations, Assessment, Development and Evaluation and proposed 34 recommendations for 20 key questions. Our goal is to promote the appropriate implementation of kangaroo mother care in clinical practice.

Neonatal outcomes from a quasi-experimental clinical trial of Family Integrated Care versus Family-Centered Care for preterm infants in U.S. NICUs

BACKGROUND

Family Integrated Care (FICare) benefits preterm infants compared with Family-Centered Care (FCC), but research is lacking in United States (US) Neonatal Intensive Care Units (NICUs). The outcomes for infants of implementing FICare in the US are unknown given differences in parental leave benefits and health care delivery between the US and other countries where FICare is used. We compared preterm weight and discharge outcomes between FCC and mobile-enhanced FICare (mFICare) in the US.

METHODS

In this quasi-experimental study, we enrolled preterm infant (≤ 33 weeks)/parent dyads from 3 NICUs into sequential cohorts: FCC or mFICare. Our primary outcome was 21-day change in weight z-scores. Our secondary outcomes were nosocomial infection, bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), and human milk feeding (HMF) at discharge. We used intention-to-treat analyses to examine the effect of the FCC and mFICare models overall and per protocol analyses to examine the effects of the mFICare intervention components.

FINDINGS

253 infant/parent dyads participated (141 FCC; 112 mFICare). There were no parent-related adverse events in either group. In intention-to-treat analyses, we found no group differences in weight, ROP, BPD or HMF. The FCC cohort had 2.6-times (95% CI: 1.0, 6.7) higher odds of nosocomial infection than the mFICare cohort. In per-protocol analyses, we found that infants whose parents did not receive parent mentoring or participate in rounds lost more weight relative to age-based norms (group-difference=-0.128, CI: -0.227, -0.030; group-difference=-0.084, CI: -0.154, -0.015, respectively). Infants whose parents did not participate in rounds or group education had 2.9-times (CI: 1.0, 9.1) and 3.8-times (CI: 1.2, 14.3) higher odds of nosocomial infection, respectively.

CONCLUSION

We found indications that mFICare may have direct benefits on infant outcomes such as weight gain and nosocomial infection. Future studies using implementation science designs are needed to optimize intervention delivery and determine acute and long-term infant and family outcomes.

CLINICAL TRIAL REGISTRATION

NCT03418870 01/02/2018.

Parental participation in the care of hospitalized neonates in low- and middle-income countries: A systematic review and meta-analysis

Introduction

To determine the effect of parental participation in hospital care on neonatal and parental outcomes in low- and middle-income countries (LMICs) and to identify the range of parental duties in the care of hospitalized neonates in LMICs.

Methods

We searched CINAHL, CENTRAL, LILACs, MEDLINE, EMBASE and Web of Science from inception to February 2022. Randomized and non-randomized studies from LMICs were eligible if parents performed one or more roles traditionally undertaken by healthcare staff. The primary outcome was hospital length-of-stay. Secondary outcomes included mortality, readmission, breastfeeding, growth, development and parental well-being. Data was extracted in duplicate by two independent reviewers using a piloted extraction form.

Results

Eighteen studies (eight randomized and ten non-randomized) were included from seven middle-income countries. The types of parental participation included hygiene and infection prevention, feeding, monitoring and documentation, respiratory care, developmental care, medication administration and decision making. Meta-analyses showed that parental participation was not associated with hospital length-of-stay (MD -2.35, 95% CI -6.78-2.07). However, parental involvement was associated with decreased mortality (OR 0.46, 95% CI 0.22-0.95), increased breastfeeding (OR 2.97 95% CI 1.65-5.35) and decreased hospital readmission (OR 0.36, 95% CI 0.16-0.81). Narrative synthesis demonstrated additional benefits for growth, short-term neurodevelopment and parental well-being. Ten of the eighteen studies had a high risk of bias.

Conclusion

Parental participation in neonatal hospital care is associated with improvement in several key neonatal outcomes in middle-income countries. The lack of data from low-income countries suggests that there remains barriers to parental participation in resource-poor settings.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=187562], identifier [CRD42020187562].

Family Involvement in the Routine Care of Hospitalized Preterm or Low Birth Weight Infants: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVES

Preterm and low birth weight (LBW) infants are often separated from parents during hospitalization. Our objective was to assess effects of interventions to increase family involvement in the routine newborn care of preterm or LBW infants compared with standard NICU care on infant and parental outcomes.

METHODS

Data sources include Medline, Embase, CINAHL, and World Health Organization Global Index Medicus to August 2021. The study selection included randomized controlled trials (RCTs) of family involvement intervention packages. Data were extracted and pooled with random-effects models.

RESULTS

We included 15 RCTs with 5240 participants. All interventions included direct parental bedside care; packages varied with respect to additional components. Family involvement interventions decreased retinopathy of prematurity (odds ratio 0.52, 95% confidence interval [CI]: 0.34, 0.80; 8 RCTs), length of hospital stay (mean difference [MD] -2.91 days; 95% CI: -5.15,-0.82; 11 RCTs), and parental stress and anxiety (Parental Stress Scale: MD -0.29 points, 95% CI: -0.56,-0.01, 2 RCTs; Anxiety State-Trait scale: MD -1.79, 95% CI: -3.11,-0.48; 2 RCTs). Family involvement increased weight gain velocity (MD 2.09 g/day; 95% CI: 1.27, 2.91; 3 RCTs), neurobehavioral exam scores (MD: 1.11; 95% CI: 0.21, 2.01; 2 RCTs) and predominant or exclusive breastmilk intake (odds ratio 1.34; 95% CI: 1.01, 1.65; 3 RCTs). It may decrease rates of bronchopulmonary dysplasia, infection, and intraventricular hemorrhage. There were no effects on mortality or necrotizing enterocolitis. Certainty of evidence ranged from low to moderate.

CONCLUSIONS

Family involvement has a beneficial role on several infant and parental outcomes.

Lower Maternal Chronic Physiological Stress and Better Child Behavior at 18 Months: Follow-Up of a Cluster Randomized Trial of Neonatal Intensive Care Unit Family Integrated Care

OBJECTIVE

To assess whether Family Integrated Care (FICare) in the neonatal intensive care unit improves maternal chronic physiological stress and child behavior at 18 months of corrected age for infants born preterm.

STUDY DESIGN

Follow-up of a multicenter, prospective cluster-randomized controlled trial comparing FICare and standard care of children born at <33 weeks of gestation and parents, stratified by tertiary neonatal intensive care units, across Canada. Primary outcomes at 18 months of corrected age were maternal stress hormones (cortisol, ie, hair cumulative cortisol [HCC], dehydroepiandrosterone [DHEA]) assayed from hair samples. Secondary outcomes included maternal reports of parenting stress, child behaviors (Internalizing, Externalizing, Dysregulation), and observer-rated caregiving behaviors. Outcomes were analyzed using multilevel modeling.

RESULTS

We included 126 mother-child dyads from 12 sites (6 FICare sites, n = 83; 6 standard care sites, n = 43). FICare intervention significantly lowered maternal physiological stress as indicated by HCC (B = -0.22 [-0.41, -0.04]) and cortisol/DHEA ratio (B = -0.25 [-0.48, -0.02]), but not DHEA (B = 0.01 [-0.11, 0.14]). Enrollment in FICare led to lower child Internalizing (B = -0.93 [-2.33, 0.02]) and Externalizing behavior T scores (B = -0.91 [-2.25, -0.01]) via improvements to maternal HCC (mediation). FICare buffered the negative effects of high maternal HCC on child Dysregulation T scores (B = -11.40 [-23.01, 0.21]; moderation). For mothers reporting high parenting stress at 18 months, FICare was related to lower Dysregulation T scores via maternal HCC; moderated mediation = -0.17 (-0.41, -0.01).

CONCLUSIONS

FICare has long-term beneficial effects for mother and child, attenuating maternal chronic physiological stress, and improving child behavior in toddlerhood.

CLINICAL TRIAL REGISTRATION

NCT01852695.

Do small baby units improve extremely premature infant outcomes?

Increasing numbers of neonatal intensive care units have formed small baby units or small baby teams with the intention to optimize care of extremely premature infants. Considerable time, energy, and resources are required to develop and sustain complex quality improvement constructs, so legitimate questions about effectiveness, unintended consequences, and lost opportunity costs warrant scrutiny. The small baby unit literature is diminutive. Errors of chance, bias, and confounding secondary to insufficient definitions of process and outcome metrics, overlapping quality improvement projects, and limited cost analyses restrict firm conclusions. Well-established quality improvement methodologies such as evidence-based guidelines, standardized variability reduction using measurement-and-adjust techniques, family-integrated focus, and developmentally sensitive care, reliably improve outcomes for all-sized premature infants. There is not compelling published evidence that adding specialized small baby units or designated teams for extremely premature infants further enhances short- or long-term health if robust quality improvement fundamentals are already imbedded within local culture.

A prospective cohort study on lactation status and breastfeeding challenges in mothers giving birth to preterm infants

Background

Mothers of preterm infants face many challenges in breastfeeding, especially regarding lactation. This study aimed to investigate the lactation status and challenges in breastfeeding faced by preterm infants’ mothers.

Methods

We approached 124 mothers who gave birth to preterm infants between 26 May and 31 October 2018 in a tertiary hospital in China. Lactation status and challenges in breastfeeding on day 7 postpartum, at discharge of infants, 2 weeks post-discharge, and 3 months of corrected age were collected using questionnaires. The area under the receiver operating characteristic (ROC) curve for expressed milk volume on day 7 postpartum for predicting expressed milk volume ≥ 300 mL/d at discharge was calculated. Logistic regression analyses were performed to identify factors associated with delayed lactogenesis II onset and continuation of breastfeeding at 3 months of corrected age.

Results

Seventy mothers were enrolled, and 51.4% had delayed lactogenesis II. Multivariate logistic regression analysis revealed that older maternal age (aOR = 1.19; 95% CI: 1.01, 1.40) and first live birth (aOR = 4.81; 95% CI 1.43, 16.18) were significant independent predictors of delayed lactogenesis II. Mothers with delayed lactogenesis II had significantly lower expressed milk volume (day 7 postpartum: 160.0 mL vs. 300.0 mL, U = 328.50, p = 0.001; at discharge: 425.0 mL vs. 612.5 mL, U = 372.00, p = 0.005), with a lower proportion of exclusive breastfeeding in their infants (at discharge: 33.3% vs. 69.8%, χ² = 12.39, df = 1, p < 0.001; 3 months of corrected age: 17.8% vs. 52.8%, χ² = 11.03, df = 1, p = 0.001). The ROC showed that expressed milk volume > 190 mL/d on day 7 postpartum significantly predicted expressed milk volume ≥ 300 mL/d at discharge. Insufficient human milk was the main reason for breastfeeding discontinuation at 3 months of corrected age. Twins were less likely to continue breastfeeding at 3 months of corrected age (aOR = 0.27; 95% CI 0.09, 0.86). In singleton infants, mother’s own milk ≥50% of total milk uptake at 2 weeks post-discharge (aOR = 32.66; 95% CI 3.00, 355.25) was an independent predictor of continuous breastfeeding at 3 months of corrected age. Feeding complications in infants, poor breastfeeding technique, and low milk output are the main challenges in breastfeeding.

Conclusion

Interventions to improve early postpartum lactation and breastfeeding techniques may increase breastfeeding adoption in mothers of preterm infants.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-021-00447-4.

Home oxygen use and 1-year outcome among preterm infants with bronchopulmonary dysplasia discharged from a Chinese regional NICU

OBJECTIVE

This study aims to compare the clinical characteristics and 1-year outcomes of preterm infants with bronchopulmonary dysplasia (BPD) who were discharged on supplemental oxygen or room air.

MATERIALS AND METHODS

The preterm infants (born <32 weeks' gestation, birth weight ≤1,250 g) diagnosed with BPD and admitted between January 2020 and December 2020 were enrolled. The clinical data during hospitalization were collected through the hospital's electronic record system. The outcomes after discharge were acquired from the outpatient system and through telephonic interviews.

RESULTS

Of the 87 preterm infants diagnosed with BPD, 81 infants survived until discharge. The 81 infants were divided into the home oxygen group (n = 29) and room air group (n = 52) according to supplemental oxygen or not at discharge. Infants in the home oxygen group were more likely to receive postnatal systemic steroids and higher ventilation settings at 36 weeks' PMA. There was one patient in each group who died before 1 year corrected age, respectively. All the infants had successfully weaned off oxygen eventually during the first year. The median duration of home oxygen therapy was 25 (7,42) days. Readmission occurred in 49 (64.5%) infants. Readmissions for infants with home oxygen were more often related to respiratory disease. In addition, wheezing disorders and home inhalation occurred more frequently in the home oxygen group (p = 0.022, p = 0.004). Although the incidence of underweight at 1 year corrected age was higher in the room air group (10.0 vs. 3.8%), there was no significant difference (p = 0.620). The rate of neurodevelopmental impairment was similar between these two groups (26.0 vs. 30.8%, p = 0.659).

CONCLUSIONS

It was the first study focused on preterm infants with BPD receiving home oxygen in China. Infants with home oxygen were more likely to have respiratory problems after discharge from NICU. Home oxygen use was not associated with more readmission for infants with BPD, and no difference was found in neurodevelopmental impairment and growth outcome.

Effectiveness of Alberta Family-Integrated Care on Neonatal Outcomes: A Cluster Randomized Controlled Trial

Family-Integrated Care (FICare) empowers parents to play an active role as a caregiver for their infant in the neonatal intensive care unit (NICU). This model of care is associated with improved neonatal outcomes, such as improved weight gain and higher breastfeeding rates at discharge in infants admitted to level III NICUs; however, its effectiveness in level II NICUs remains unproven. The objective of this study was to evaluate the effectiveness of the model on neonatal outcomes in a cluster randomized controlled trial conducted in 10 level II NICUs randomized to Alberta FICare or standard care. Mothers and their preterm infants born between 32⁺⁰ and 34⁺⁶ weeks' gestational age were included. The primary outcome was the proportion of infants who regained their birth weight (BW) after 14 days of life. The analysis included 353 infants/308 mothers at Alberta FICare sites and 365 infants/306 mothers at standard care sites. There was no difference in the proportion of infants who had regained their BW by 14 days between the groups. A lack of perceived improved weight gain trajectory for those in the FICare group is attributed to a shorter length of hospital stay and infants being discharged prior to regaining BW.

Family integrated care: Supporting parents as primary caregivers in the neonatal intensive care unit

Family integrated care (FICare) is a collaborative model of neonatal care which aims to address the negative impacts of the neonatal intensive care unit (NICU) environment by involving parents as equal partners, minimizing separation, and supporting parent-infant closeness. FICare incorporates psychological, educational, communication, and environmental strategies to support parents to cope with the NICU environment and to prepare them to be able to emotionally, cognitively, and physically care for their infant. FICare has been associated with improved infant feeding, growth, and parent wellbeing and self-efficacy; important mediators for long-term improved infant neurodevelopmental and behavioural outcomes. FICare implementation requires multi-disciplinary commitment, staff motivation, and sufficient time for preparation and readiness for change as professionals relinquish power and control to instead develop collaborative partnerships with parents. Successful FICare implementation and culture change have been applied by neonatal teams internationally, using practical approaches suited to their local environments. Strategies such as parent and staff meetings and relational communication help to break down barriers to change by providing space for the co-creation of knowledge, the negotiation of caregiving roles and the development of trusting relationships. The COVID-19 pandemic highlighted the vulnerability within programs supporting parental presence in neonatal units and the profound impacts of parent-infant separation. New technologies and digital innovations can help to mitigate these challenges, and support renewed efforts to embed FICare philosophy and practice in neonatal care during the COVID-19 recovery and beyond.

On "Parents' Experiences With a Model of Integrated Maternity and Neonatal Care Designed to Empower Parents"

The idea of intervening with the family as a whole using an integrated model of care is an important goal for practice and future research.

Assessment of feasibility and acceptability of family-centered care implemented at a neonatal intensive care unit in India

Background

A family-centered care (FCC) parent participation program that ensures an infant is not separated from parents against their will was developed for the caring of their small or sick newborn at a neonatal intensive care unit (NICU) in Delhi, India. Healthcare provider sensitization training directed at psychosocial and tangible support and an audio-visual training tool for parent-attendants were developed that included: 1) handwashing, infection prevention, protocol for entry; 2) developmentally supportive care, breastfeeding, expression of breastmilk and assisted feeding; 3) kangaroo mother care; and 4) preparation for discharge and care at home. The study aimed to examine the feasibility and acceptability of the FCC model in a NICU in India.

Methods

A prospective cohort design collected quantitative data on each parent-attendant/infant dyad at enrollment, during the NICU stay, and at discharge. Feasibility of the FCC program was measured by assessing the participation of parent-attendants and healthcare providers, and whether training components were implemented as intended. Acceptability was measured by the proportion of parent-attendants who participated in the trainings and their ability to accurately complete program activities.

Results

Of 395 NICU admissions during the study period, eligible participants included 333 parent-attendant/infant dyads, 24 doctors, and 21 nurses. Of the 1242 planned parent-attendant training sessions, 939 (75.6%) were held, indicating that program fidelity was high, and the majority of trainings were implemented as intended. While 50% of parent-attendants completed all 4 FCC training sessions, 95% completed sessions 1 and 2; 60% of the total participating parent-attendants completed session 3, and 75% completed session 4. Compliance rates were over 96% for 5 of 10 FCC parent-attendant activities, and 60 to 78% for the remaining 5 activities.

Conclusions

FCC was feasible to implement in this setting and was acceptable to participating parent-attendants and healthcare providers. Parents participated in trainings conducted by NICU providers and engaged in essential care to their infants in the NICU. A standard care approach and behavior norms for healthcare providers directed psychosocial and tangible support to parent-attendants so that a child is not separated from his or her parents against their will while receiving advanced care in the NICU.

Influence of Family Integrated Care on the Intestinal Microbiome of Preterm Infants With Necrotizing Enterocolitis and Enterostomy: A Preliminary Study

The aim of this study was to investigate the influence of family integrated care (FICare) on the intestinal microbiome of preterm infants with necrotizing enterocolitis and enterostomy. This was a prospective pilot study at Beijing Children's Hospital. Premature infants with an enterostomy who met the enrollment criteria were divided into the 2-week FICare and non-FICare groups (non-randomly). We collected their fecal samples and subjected the intestinal microbiomes to 16S rRNA gene sequencing. Operational taxonomic units (OTU) were analyzed to assess the intestinal microbiome richness, and we then carried out α-diversity, β-diversity, and species clustering analyses and a linear discriminant analysis (LDA) effect size (LEfSe) analysis to identify the differences in the microbial communities between the two groups. There were 12 patients enrolled in the study (FICare, n = 7; non-FICare, n = 5). There were no significant between-group differences in demographic characteristics, or in the relative abundances of phyla and genera. The major bacterial phyla were Proteobacteria, Firmicutes, and Actinobacteria, and Serratia, Enterococcus, Cronobacter, and Bifidobacterium dominated at the genus level. The α-diversity analysis indicated that the intestinal flora was more diverse in the non-FICare group than the FICare group (p < 0.05). However, most of the other indicators did not suggest a difference between the two groups. There was a high proportion of shared OTUs between the two groups, and the PCoA and clustering analyses indicated that the two groups were difficult to distinguish, indicating that the intestinal microbiomes were relatively similar between the groups. In summary, short-term FICare had no significant positive effect on the establishment of intestinal flora diversity in premature infants with necrotizing enterocolitis and enterostomy. The trial was registered in the Chinese Clinical Trial Registry (ChiCTR-OPN-17011801).

Scaling Up the Family Integrated Care Model in a Level IIIC Neonatal Intensive Care Unit: A Systematic Approach to the Methods and Effort Taken for Implementation

Background: Family Integrated Care (FICare) integrates parents in the direct care of their child while the healthcare personnel act as teachers and guides. To this date, most reports on the feasibility of this model refer to stable preterm infants admitted to Neonatal Intensive Care Units (NICUs). Objectives: To scale up and adapt FICare to make it suitable in level IIIC NICUs, which care for extreme prematurity and other complex medical or surgical neonatal conditions. Materials and Methods: Step 1 was the creation of the FICare implementation team (FICare-IT) and baseline analysis of current procedures for critical care to identify needs, wishes, and requirements; we aimed for protocol elaboration tailored to our cultural, architectural, and clinical context (March 2017 to April 2018). Step 2 as a dissemination strategy by FICare-IT acting as primary trainers and mentors to ensure the education of 90% of nursing staff (May 2018 to July 2018). Step 3 involved piloting and evaluation with the aim to refine the procedure (July 2018 to December 2020). Results: A rigorous but flexible protocol was edited. The FICare educational manual included two curricula: for healthcare professionals/staff (Training the trainers) and for families (Education of caregivers), the latter being categorized in two intervention levels (basic and advanced), depending on the infant care needs and parent's decision. In total, 76 families and 91 infants (74.7% preterm; 18.7% complex surgery; 6.6% others) were enrolled in the pilot. No differences in acceptance rate (overall 86.4%) or in the number of infant-family dyads in the program per month were observed when considering the pre- and post-Covid-19 pandemic periods. All families, except for one who dropped out of the program, completed the agreed individualized training. Mothers spent more time in NICU than fathers (p < 0.05); uninterrupted time spent by mothers in NICU was longer during the pre-pandemic period (p < 0.01). Observed time to reach proficiency by task was within the expected time in 70% of the program contents. The parents revealed educational manuals, workshops, and cot-side teaching sessions as essential for their training, and 100% said they would accept entry into the FICare program again. Conclusions: The principles of the FICare model are suitable for all levels of care in NICUs. Leadership and continuous evaluation/refinement of implementation procedures are essential components to achieve the objectives.