Parental presence and holding in the neonatal intensive care unit and associations with early neurobehavior

Understanding family-centered care in the NICU: a scoping review protocol

OBJECTIVE

This scoping review will aim to identify and categorize the definitions of neonatal intensive care unit (NICU) family-centered care (FCC) and its associated concepts. It also aims to identify and categorize the practices and interventions that comprise NICU FCC, and catalog the metrics used to evaluate NICU FCC.

INTRODUCTION

FCC has been identified as an important element of care for neonates and infants admitted to the NICU, and there is clear evidence that the incorporation of families in care improves clinical outcomes. However, FCC has been linked to numerous associated terms and concepts and lacks a unifying definition or framework, thus limiting the ability to categorize, prioritize, and identify practices and interventions to optimize both institutional approaches for individual centers and for the field at large.

INCLUSION CRITERIA

Studies that include or apply at least one FCC concept or its associated terms will be considered eligible for inclusion. Studies not related exclusively to the NICU will be excluded.

METHODS

The review will follow the JBI methodology for scoping reviews and will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Several electronic databases and sources of gray literature will be searched from 1992 to the present day. The review will include only full-text studies in English and will be independently screened by a minimum of 2 authors. Data will be extracted using a modified JBI data extraction tool and presented using narrative summaries; concept mapping; and categorization of practices, interventions, and metrics.

Families as partners in neonatal neuro-critical care programs

Parents of neonates with neurologic conditions face a specific breadth of emotional, logistical, and social challenges, including difficulties coping with prognostic uncertainty, the need to make complex medical decisions, and navigating new hopes and fears. These challenges place parents in a vulnerable position and at risk of developing mental health issues, which can interfere with bonding and caring for their neonate, as well as compromise their neonate's long-term neurodevelopment. To optimize neurologic and developmental outcomes, emerging neonatal neuro-critical care (NNCC) programs must concurrently attend to the unique needs of the developing newborn brain and of his/her parents. This can only be accomplished by embracing a family-centered care environment-one which prioritizes effective parent-clinician communication, longitudinal parent support, and parents as equitable partners in clinical care. NNCC programs offer a multifaceted approach to critical care for neonates at-risk for neurodevelopmental impairments, integrating expertise in neonatology and neurology. This review highlights evidence-based strategies to guide NNCC programs in developing a family-partnered approach to care, including primary staffing models; staff communication, implicit bias, and cultural competency trainings; comprehensive and tailored caregiver training; single-family rooms; flexible visitation policies; colocalized neonatal and maternal care; uniform mental health screenings; follow-up care referrals; and connections to peer support. IMPACT: Parents of neonates with neurologic conditions are at high-risk for experiencing mental health issues, which can adversely impact the parent-neonate relationship and long-term neurodevelopmental outcomes of their neonates. While guidelines to promote families as partners in the neonatal intensive care unit (NICU) have been developed, no protocols integrate the unique needs of parents in neonatal neurologic populations. A holistic approach that makes families true partners in the care of their neonate with a neurologic condition in the NICU has the potential to improve mental and physical well-being for both parents and neonates.

aEEG in the first 3 days after extremely preterm delivery relates to neurodevelopmental outcomes

OBJECTIVES

Investigate relationships between aEEG in the first 72 h in extremely preterm infants with 1) infant, medical, and environmental factors, and 2) infant feeding and neurobehavioral outcomes at term and school-age.

METHODS

Sixty-four preterm infants (≤28 weeks gestation) were enrolled within the first 24-hours of life and had two-channel aEEG until 72 h of life. Standardized neurobehavioral and feeding assessments were conducted at term, and parent-reported outcomes were documented at 5-7 years.

RESULTS

Lower aEEG Burdjalov scores (adjusted for gestational age) were related to vaginal delivery (p = 0.04), cerebral injury (p = 0.01), Black race (p < 0.01) and having unmarried parents (p = 0.02). Lower Burdjalov scores related to less NICU Network Neurobehavioral Scale arousal (p = 0.002) at term and poorer BRIEF global executive function (p = 0.004), inhibition (p = 0.007), working memory (p = 0.02), material organization (p = 0.0008), metacognition (p = 0.01), and behavioral regulation (p = 0.02) at 5-7 years. We did not observe relationships of early aEEG to feeding outcomes or sensory processing measures.

CONCLUSION

Early aEEG within the first 72 h of life was related to medical and sociodemographic factors as well as cognitive outcome at 5-7 years.

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

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.

Impact of Parent Presence and Engagement on Stress in NICU Infants

BACKGROUND

Infants in neonatal intensive care units (NICUs) are exposed to frequent stressors that impact their neurodevelopmental outcomes. Parent presence and engagement are considered critical to improving infant outcomes, yet associations between cumulative NICU parent presence, engagement, and infant stress are infrequently examined.

PURPOSE

To examine associations between NICU infant stress and the amount (hours per week) or frequency (days per week) of parent presence and skin-to-skin care (SSC).

METHODS

A secondary analysis of a data set representing 78 NICU families was conducted. Infant acuity was measured using Neonatal Medical Index (NMI) scores. Parent presence and SSC data were collected from electronic medical records. Infant stress was measured using resting salivary cortisol levels collected at NICU discharge (median = 33 days of life).

RESULTS

More cumulative SSC was associated with lower discharge cortisol in NICU infants for SSC measured in hours per week (P = .03) or days per week (P = .05). Cumulative parent presence was not significantly associated with infant cortisol at discharge. Hierarchical regression analyses examining timing of parent presence supported a model including admission cortisol, NMI score, and parent presence during weeks 1 to 4 of life for explaining infant stress at discharge (R2 = 0.44, P = .004). Analyses examining timing of SSC supported a model including admission cortisol, NMI score, and frequency of SSC during week 1 for explaining infant stress at discharge (R2 = 0.21, P = .04).

IMPLICATIONS FOR PRACTICE AND RESEARCH

Early, frequent SSC to mitigate stress in NICU infants was supported. Results suggested that timing of parent presence impacts NICU infant stress; however, additional study is recommended.

Neurodevelopmental Outcomes following Preterm Birth and the Association with Postmenstrual Age at Discharge

OBJECTIVE

This study aimed to (1) define the prevalence of motor, cognitive, and language delays in preterm infants born <32 weeks estimated gestational age (EGA); and (2) identify the relationship between the timing of discharge from the neonatal intensive care unit (NICU) and neurodevelopmental outcome in early childhood.

STUDY DESIGN

This retrospective study of 172 preterm infants born <32 weeks EGA and hospitalized in a level-IV NICU captured medical factors, including timing of discharge, from the NICU stay. Standardized developmental testing at 1 to 2 years corrected age was conducted in the newborn follow-up clinic.

RESULTS

At 1 to 2 years corrected age, the sample had an average Bayley Scales of Infant and Toddler Development (Bayley-III) cognitive composite score of 91.5 ± 17.4, language composite score of 84.5 ± 17.3, and motor composite score of 88.9 ± 18.4. Lower EGA at birth, necrotizing enterocolitis, patent ductus arteriosus, and oxygen requirement for >28 days were independently associated with higher postmenstrual age (PMA) at NICU discharge. Higher PMA at discharge was associated with poorer cognitive outcome [p < 0.001, β = -1.1 (-1.6, -0.7)], poorer language outcome [p = 0.049, β = -0.5 (-0.9, -0.003)], and poorer motor outcome [p <0.001, β = -1.0 (-1.5, -0.5)]. For every additional week of hospitalization, scores were an average of 1.1 points lower in cognitive, 1.0 point lower in motor, and 0.5 points lower in language domains of the Bayley-III assessment.

CONCLUSION

Poorer cognitive, language, and motor outcomes were associated with longer hospitalization, even after controlling for medical risk factors known to be associated with poorer outcome. This provides further evidence for the potential role of the environment in impacting developmental outcomes of infants hospitalized in the NICU.

KEY POINTS

· There are high rates of developmental impairment among preterm infants born <32 weeks at 1 year to 2 years.. · The longer the infant is exposed to the NICU environment, the higher the risk of neurodevelopmental challenges.. · These findings provide increased motivation for optimizing the early NICU environment..

Parent and grandparent neonatal intensive care unit visitation for preterm infants

OBJECTIVE

Characterize family NICU visitation and examine associations with maternal health and social factors and infant health outcomes.

STUDY DESIGN

Retrospective cohort study of 167 infants born ≤32 weeks at two urban NICUs 01/2019-03/2020. Average nurse-documented family member visitation and associations of visitation with maternal and infant factors and outcomes were compared.

RESULTS

Mothers visited 4.4 days/week, fathers 2.6 days/week, and grandparents 0.4 days/week. Older maternal age, nulliparity, and non-English primary language were associated with more frequent family visitation. Mothers with depression or anxiety history visited less. Maternal depression and public insurance were associated with fewer father visits. Low parental visitation was associated with lower odds of feeding any maternal milk at discharge and low maternal visitation with 11.5% fewer completed infant subspecialty appointments in the year following discharge (95% CI -20.0%, -3.0%).

CONCLUSION

Families with social disadvantage visited less often. Parental visitation was associated with infant feeding and follow-up.

Prescription for Cash? Cash Support to Low-Income Families in Maternal and Pediatric Health Care Settings

Policy Points Pregnancy and childhood are periods of heightened economic vulnerability, but current policies for addressing health-related social needs, including screening and referral programs, may be insufficient because of persistent gaps, incomplete follow-up, administrative burden, and limited take-up. To bridge gaps in the social safety net, direct provision of cash transfers to low-income families experiencing health challenges during pregnancy, infancy, and early childhood could provide families with the flexibility and support to enable caregiving, increase access to health care, and improve health outcomes.

Unconditional cash transfers for preterm neonates: evidence, policy implications, and next steps for research

To address socioeconomic disparities in the health outcomes of preterm infants, we must move beyond describing these disparities and focus on the development and implementation of interventions that disrupt the factors contributing to them. Unconditional cash transfers (UCTs), which provide unrestricted payments to individuals or households, can help mitigate income disparities and improve health outcomes. While UCTs have been utilized for other vulnerable populations, their full potential has yet to be realized for low-income families with preterm infants, who face significant financial strain. In this perspective, we review evidence supporting UCTs as an intervention for children in the U.S. (including those born term and preterm), discuss the potential benefits of recurring UCTs to low-income families of preterm infants, and propose a conceptual model through which UCTs may improve outcomes for preterm infants. We conclude with potential policy levers for implementing UCTs and key unanswered questions for researchers.

Organizational Barriers to and Facilitators of the Successful Implementation and Sustainability of the Supporting and Enhancing NICU Sensory Experiences (SENSE) Program

IMPORTANCE

The Supporting and Enhancing NICU Sensory Experiences (SENSE) program is an evidence-based intervention that promotes daily, positive sensory exposures for infants in the neonatal intensive care unit (NICU). Understanding program implementation across sites may aid in optimizing strategies for uptake of the program and subsequently improve outcomes for infants and families.

OBJECTIVE

To investigate health care professionals' perceptions of implementing the SENSE program.

DESIGN

The SENSE Program Implementation Survey was developed using Proctor et al.'s model and the BARRIERS scale to probe organizational practices across sites worldwide.

SETTING

Survey distributed to 211 hospitals with a SENSE program license obtained before March 2020.

PARTICIPANTS

One hundred fourteen NICU personnel (response rate = 54%).

OUTCOMES AND MEASURES

The survey sought to understand barriers and facilitators, adaptations during implementation, and associated costs.

RESULTS

Of the 53% (n = 57 of 107) of respondents who had implemented the SENSE program, many (n = 14; 31%) experienced quick timing (<1 mo) to use, including spread to nearly all infants in their NICU within 6 mo (n = 18; 35%). Most reported the program was used to educate families ≤3 days of birth (n = 20/59; 34%). Most of the sensory interventions in the program were performed by parents (n = 38; 67%) and therapists (n = 44; 77%). Barriers and facilitators at the organizational and individual levels were identified. No additional staff were hired to implement the program.

CONCLUSIONS AND RELEVANCE

Given perceived successes and challenges, strategic enhancement of implementation can inform future administrations of the SENSE program. Plain-Language Summary: This study provides occupational therapists who are interested in implementing the SENSE program (Supporting and Enhancing NICU Sensory Experiences) with an understanding of common barriers, facilitators, costs, and adaptations, which can be used to advocate for program implementation in NICUs to improve outcomes for preterm infants worldwide.

Infant and Parent Outcomes Related to NICU-Based Co-occupational Engagement

Neonatal intensive care unit (NICU) co-occupations may impact parent-infant outcomes. The main objective of this study was to explore relationships between parent and infant outcomes based on whether sensory-based interventions (co-occupations) occurred most often between parent-infant dyads or provider/volunteer-infant dyads. Thirty-five families received the Supporting and Enhancing NICU Sensory Experiences (SENSE) program, which includes education defining specific amounts of sensory exposures for infants to receive each day of NICU hospitalization (with a preference for parent delivery). Infant sensory experiences in the NICU were logged, and dyads were grouped based on who conducted most of the sensory interventions with the infant in the NICU into a Parent-Infant Co-occupation group or Other Administered group. The Parent-Infant Co-occupation group had infants with less lethargy on the NICU Network Neurobehavioral Scale (p = .04), and parents with lower scores on the Parental Stress Scale (p = .003) and State-Trait Anxiety Inventory-state (p = .047). Parent-infant engagement in co-occupations was related to parental mental health and infant neurobehavior.

NICU Couplet Care: metrics to guide an evolving model of care

OBJECTIVE

The evidence-based science of maternal and neonatal care has been rapidly changing. As a result, clinical practice and the design of physical space have evolved in order to provide neuroprotection for the baby and meet expectations of family presence and participation.

SETTING

The concept and practice of NICU Couplet Care supports positive health well-being/outcomes and early relationship building between the mother-baby-father/partner.

RESULTS

Monitoring evidence-based measures and metrics of standardized care, performance competence, neuro-physical and psychosocial outcomes, environmental design, family and staff satisfaction, and sustainability are essential to the evolution of quality, safe, efficient, effective, ethical, and cost-effective care for the mother, baby, and family. Transparency in the dissemination of evidence, practice standards, and outcome data is important to guide parents/families and health professionals in making informed shared decisions regarding the clinical care provided and the environment where care takes place.

Parental holding of infants improves haemodynamics in the cardiac ICU

We performed a single-centre, retrospective study to assess physiologic changes of infants in the cardiac ICU while being held by their parent. Continuous data streaming of vital signs were collected for infants included in the study from January 2021 to March 2022. Demographic and clinical characteristics were collected from the electronic medical record. The physiologic streaming data were analysed using mixed-effects models to account for repeated measures and quantify the effect of parental holding. Comparison analysis was also performed controlling for intubation, pre-operative versus post-operative status, and whether the holding was skin-to-skin or not. Ninety-five patients with complete physiologic data were included in the study. There were no immediate adverse events associated with holding. Heart rate decreased during the response time compared to its baseline value (p = 0.01), and this decrease was more pronounced for the non-intubated and pre-operative patients. The near-infrared spectroscopy-based venous saturation increased overall (p = 0.02) in patients while being held. We conclude that parental holding of infants in the cardiac ICU can be safely accomplished, and the haemodynamic and oximetric profile during the holding is favourable compared to the infants' baseline prior to holding.

Implementing Guidelines for NICU Parent Presence: Effects on Parent and Infant Stress

BACKGROUND

Relationships between parents and infants are essential for mitigating stressors encountered in neonatal intensive care units (NICUs) and are supported by parent presence and engagement.

PURPOSE

The purpose of this study was to compare NICU parent and infant outcomes pre- and postimplementation of an intervention aimed at increasing parent presence and engagement in the NICU. This family-centered care intervention consisted of communicating specific guidelines for parent presence.

METHODS

Data related to parent presence, skin-to-skin care, and breastfeeding; parental stress; infant outcomes including weight gain, length of stay, feeding status at discharge, and stress; and unit-level outcomes were collected from a convenience sample of 40 NICU families recruited preimplementation and compared with data for 38 NICU families recruited postimplementation of specific guidelines for parent presence. To establish comparability of groups, infants were assigned scores using the Neonatal Medical Index.

RESULTS

Parent presence, engagement in skin-to-skin care, and breastfeeding rates were not significantly different between groups. Stress-related outcomes were significantly decreased in NICU mothers, fathers, and infants, and infant feeding outcomes were improved in the postintervention group.

CONCLUSIONS

Specific guidelines for parent presence may represent an invitation for parents to engage with their NICU infants and may positively impact parent and infant stress.

Feasibility of wearable sensors in the NICU: Psychophysiological measures of parental stress

BACKGROUND

Parents report elevated stress during their infant's NICU hospitalization. Real-time measures may improve our understanding of parental stress in the NICU.

AIM

Examine the feasibility of wearable sensors to describe parental stress in the NICU.

STUDY DESIGN

In this prospective feasibility study of 12 parent-infant dyads, parents wore an Empatica E4 wristband to measure psychophysiological stress via electrodermal activity (EDA) during sensory interventions (holding, massage, reading, touch, etc) with their babies. Baseline and intervention periods were delineated during which concurrent monitoring and clinical observations of infant behavior and environmental factors were recorded. Feasibility was assessed by investigating recruitment/enrollment, retention/adherence, acceptability, sensor usability, and changes in EDA waveforms based on potential stressors. For the latter, independent samples t-tests and ANOVA were used to examine differences in EDA from baseline to intervention, and the impact of environmental and infant factors on parent stress were visually analyzed against EDA waveforms.

RESULTS

Wearable sensor use in the NICU appeared feasible as assessed by all methods. Preliminary data analysis indicated that overall parent EDA levels during parent-infant interactions were low, and engagement in sensory intervention(s) led to a non-significant increase in parental EDA, measured by both skin conductance levels and non-specific skin conductance responses. Three main patterns of EDA emerged: a temporary increase in EDA at the beginning of the intervention followed by a decrease and plateau, a plateau in EDA from baseline to intervention, and a gradual rise in EDA throughout intervention. Specific environmental and infant factors, such as infant stress and health care providers entering the room, appeared to impact parent stress levels.

CONCLUSION

Although these preliminary findings provide support for use of EDA in the NICU, future studies are needed.

Comparison of Parental In-Person Visitation and Webcam Usage Patterns at a Single-Center Neonatal Intensive Care Unit

Purpose

Barriers to parents visiting the neonatal intensive care unit (NICU) in person for infant bonding include socioeconomic status, distance from NICU, and having children at home. Use of NICU bedside webcam can increase access to parent-infant interaction. This study aimed to describe the pattern of webcam logins by parents, relationship of logins to in-person visitation, and maternal factors affecting usage.

Methods

In this retrospective cohort study, data pertaining to parental webcam logins and in-person visitation, maternal screening for depression, anxiety, and stress, and family sociodemographics were collected from medical records. Relationships between chart variables and webcam or in-person visitation were measured using Pearson's correlation coefficient and Mann-Whitney U test, as applicable. Login data were obtained from weeks 2 through 5 of NICU stay of the infant, while depression, anxiety, and stress scores were obtained in the second week as standard procedure by a dedicated NICU social worker.

Results

A total of 59 mother-baby dyads were included. Percentage of days visited and webcam logins decreased from week 2 to week 5. A higher rate of webcam login was documented for all parents on days they did not visit in person. Parents who lived ≥15 miles away (P=0.004) and those with government insurance (P=0.01) visited in person significantly less, although webcam logins showed no difference between groups. One negative correlation was found between percentage of in-person visits and DASS-21 depression score (P=0.03), but no such correlation was seen with webcam logins.

Conclusions

Parents utilized NICU webcams to connect with their infants when unable to be at the bedside. Webcam use reduced visitation disparities known to be exacerbated by insurance status, home-to-hospital distance, and psychological distress.

Feasibility of Implementing a Modified SENSE Program to Increase Positive Sensory Experiences for Preterm Infants in the Neonatal Intensive Care Unit (NICU): A Pilot Study

AIMS

To evaluate the feasibility of implementing the Supporting and Enhancing NICU Sensory Experiences (SENSE) program with adaptations to increase positive sensory exposure for infants born preterm, support neonatal neurodevelopment, and decrease parent stress.

METHODS

Eight infants born between 28 and 33 weeks were recruited within one week of birth. Parents, trained in the program, delivered the SENSE protocol. The first author provided up to 1 h of sensory input on weekdays when a parent could not be present.

RESULTS

Recruitment and retention rates were 87.5% and 100%, respectively. Recruitment and initial parent education and training averaged 37.5 min. On average, parents were present in the NICU 85.1% of days; they participated in SENSE for an average of 515.5 min. SENSE dose recommendations were not consistently met. Weekly infant assessments and regular parent check ins averaged 22.5 and 13.8 min, respectively. Post-assessments revealed normal scores on a neurodevelopmental assessment, low parent stress, and high parent satisfaction.

CONCLUSIONS

The recruitment and retention rates suggest high demand to participate. Outcomes for parent stress and neonatal neurodevelopment support continuation of SENSE. Time commitment for implementation, coupled with supporting families in meeting dose recommendations, suggest a need for a neonatal therapist to promote sustainability.

Transferring With TACT: A Novel Tool to Standardize Transfer Decisions From a Level IV NICU

BACKGROUND

Neonatal patients who no longer require level IV neonatal intensive care unit care are transferred to less acute levels of care. Standardized assessment tools have been shown to be beneficial in the transfer of patient care. However, no standardized tools were available to assist neonatal providers in the assessment and communication of the infants needs at transfer.

PURPOSE

The purpose was to develop a Transfer Assessment and Communication Tool (TACT) that guides provider decision making in the transfer of infants from a level IV neonatal intensive care unit to a less acute level of care within a regionalized healthcare system.

METHODS

Phase 1 included developing the first draft of the TACT using retrospective data, known variables from published literature, and study team expertise. In phase 2, the final draft of the TACT was created through feedback from expert neonatal providers in the regionalized care system using e-Delphi methodology.

RESULTS

The first draft of the TACT, developed in phase 1, included 36 characteristics. In phase 2, nurses, nurse practitioners, and physician experts representing all levels of newborn care participated in 4 e-Delphi surveys to develop the final draft of the TACT, which included 74 weighted characteristics.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Potential benefits of the TACT include improved communication across healthcare teams, reduced risk for readmission, and increased caregiver visitation. The next steps are to validate the TACT for use either retrospectively or in real time, including characteristic weights, before implementation of this tool in the clinical setting.

An integrative review of clinician-administered comforting touch interventions and acute stress responses of preterm infants

PROBLEM

Preterm infants experience numerous stressors in the neonatal intensive care unit. Non-pharmacological interventions, including maternal comforting touch, reduce stress responses of preterm infants; however, the effects of clinician-administered comforting touch are unclear. The purpose of this integrative review was to synthesize findings from clinical trials to determine the effect of clinician-administered comforting touch on preterm infants' acute stress responses.

ELIGIBILITY CRITERIA

Eligible clinical trials were published in English between 2001 and October 2021 and reported effects of clinician-administered comforting touch on acute stress responses in preterm infants.

SAMPLE

Thirty clinical trials were included.

RESULTS

Researchers tested the effect of comforting static touch, massage, massage with kinesthetic stimulation, sensorial saturation, and Yakson. There was significant heterogeneity in study design, comparison condition, and context of intervention delivery. Results varied; some studies demonstrated efficacy of comforting touch in reducing acute stress responses and others showed no effect. Generally, comforting touch provided during stressful procedures was associated with lower stress responses compared to standard care and was an effective adjunct to other stress management strategies. However, comforting touch alone was insufficient for managing pain, especially during skin-breaking procedures.

CONCLUSIONS

While comforting touch may be a useful part of stress management plans for preterm infants, additional research is needed to determine when comforting touch is appropriate and effective.

IMPLICATIONS

Comforting touch is beneficial to preterm infants and should be provided for stress management. For highly intrusive or painful procedures, comforting touch can be provided as part of a comprehensive stress management plan.

Implementation and Practice Barriers of Family-Centered Care Encountered by Neonatal Nurses

BACKGROUND

Approximately 7 out of every 100 births in the United States result in admission to the neonatal intensive care unit (NICU), which contributes to a delay in initial physical contact between the parents and their newborn. While family-centered care (FCC) increases opportunities for parent-infant connection, implementation barriers persist in clinical practice. Research has yet to examine whether organizational and nursing factors of empowerment and compassion fatigue (CF) in the NICU are associated with FCC practice.

PURPOSE

The aim of this study was to determine the relationship between empowerment, CF, and FCC practices among NICU nurses.

METHODS

This quantitative portion of a mixed-methods study used a cross-sectional, descriptive correlational design. Bedside NICU nurses with at least 6-month experience were recruited to complete an anonymous online survey using established, valid, and reliable instruments.

RESULTS

Except for organizations with Magnet status, there were no significant differences in FCC practice within individual and institutional characteristics. Hierarchical linear regression model indicated nurse empowerment was a strong predictor of FCC practice (β= 0.31, R2 = 0.35, P < .001). There was only a weak, inverse association between CF and FCC practices ( r =-0.199, P < .001).

IMPLICATION FOR RESEARCH AND PRACTICE

Further qualitative research will integrate these findings to understand the process by which neonatal nurses engage in FCC practices in the context of NICU setting. Future studies should examine facilitators and barriers of FCC practice in the NICU. Strategies (eg, policies and trainings) to increase nurse empowerment and support for FCC implementation should be developed and evaluated.

Sensory-based interventions in the NICU: systematic review of effects on preterm brain development

BACKGROUND

Infants born preterm are known to be at risk for abnormal brain development and adverse neurobehavioral outcomes. To improve early neurodevelopment, several non-pharmacological interventions have been developed and implemented in the neonatal intensive care unit (NICU). Sensory-based interventions seem to improve short-term neurodevelopmental outcomes in the inherently stressful NICU environment. However, how this type of intervention affects brain development in the preterm population remains unclear.

METHODS

A systematic review of the literature was conducted for published studies in the past 20 years reporting the effects of early, non-pharmacological, sensory-based interventions on the neonatal brain after preterm birth.

RESULTS

Twelve randomized controlled trials (RCT) reporting short-term effects of auditory, tactile, and multisensory interventions were included after the screening of 1202 articles. Large heterogeneity was identified among studies in relation to both types of intervention and outcomes. Three areas of focus for sensory interventions were identified: auditory-based, tactile-based, and multisensory interventions.

CONCLUSIONS

Diversity in interventions and outcome measures challenges the possibility to perform an integrative synthesis of results and to translate these for evidence-based clinical practice. This review identifies gaps in the literature and methodological challenges for the implementation of RCTs of sensory interventions in the NICU.

IMPACT

This paper represents the first systematic review to investigate the effect of non-pharmacological, sensory-based interventions in the NICU on neonatal brain development. Although reviewed RCTs present evidence on the impact of such interventions on the neonatal brain following preterm birth, it is not yet possible to formulate clear guidelines for clinical practice. This review integrates existing literature on the effect of sensory-based interventions on the brain after preterm birth and identifies methodological challenges for the conduction of high-quality RCTs.

A Systematic Review of the Effects of Skin-to-Skin Contact on Biomarkers of Stress in Preterm Infants and Parents

BACKGROUND

Premature infants and their parents experience significant stress related to separation and lifesaving procedures. While evidence suggests that skin-to-skin contact (SSC) is a stress-reducing intervention for both neonates and parents, the mechanisms that underlie its efficacy are not well understood.

OBJECTIVE

Purpose of this systematic review is to summarize the current state of knowledge on changes in biomarkers (ie, oxytocin [OT], cortisol, hypoxanthine, xanthine, uric acid, and allantoin), associated with SSC in premature infants and parents, that may reflect physiologic responses to stress.

METHODS

A comprehensive literature search was conducted from 1990 to 2020. Studies were selected using prespecified inclusion and exclusion criteria.

RESULTS

Of the 175 studies identified, only 19 are included in this review. Ten studies evaluated only infants, 2 evaluated only parents, and 7 evaluated for changes in biomarkers in both infants and parents. Cortisol was the most common biomarker evaluated. While changes in infants' cortisol levels were highly variable, in 55% of the parent studies, parent cortisol levels decreased following SSC. In both parents and infants, OT levels decreased following SSC. Only 1 study found that allantoin levels were significantly lower in infants who received SSC.

IMPLICATIONS FOR PRACTICE AND RESEARCH

While evidence suggests the numerous benefits of SSC, additional research is needed to identify the optimal biomarker to determine the mechanisms that underlie these effects. The use of novel biomarkers (eg, gene expression changes microbiome) may provide new insights into the mechanisms that underlie the efficacy of SSC.Video Abstract available at:https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=48.

Psychometric Properties of an Instrument to Measure the Quality of Family-Centered Care in NICUs

OBJECTIVE

To examine the psychometric properties of the Digi Family-Centered Care-Parent Version (DigiFCC-P), which was developed to measure parents' perceptions of family-centered care (FCC) in NICUs.

DESIGN

Cross-sectional psychometric study.

SETTING

Twenty-three NICUs in 15 countries in Europe, Canada, and Australia.

PARTICIPANTS

Mothers (n = 565) and fathers (n = 406) of preterm infants hospitalized in NICUs.

METHODS

Participants reported their perceptions of the quality of FCC during their infants' hospitalizations by answering one DigiFCC-P question delivered to their mobile phones every evening. Nine questions rotated in random order. Participants responded on a 7-point Likert scale. We evaluated the instrument's internal consistency, construct and concurrent validity, and sensitivity.

RESULTS

The internal consistency of the DigiFCC-P was satisfactory; the Cronbach's alpha coefficient was .74 (95% confidence interval [.71, .77]), and all the corrected item-total correlations were greater than .30. We identified that the items formed two factors, support from staff and the parent's active participation, and observed no strong item cross-loadings on the two factors. We discovered some items with weak interitem correlations, and the two factors explained 35.2% of the variance. Scores on the DigiFCC-P and Family-Centered Care Questionnaire were significantly correlated (r = .59, p < .001) and supported the convergent validity of the instrument. In addition, changes were discovered in the participants' ratings over time, which indicated that the instrument was sensitive to detect changes in their evaluations.

CONCLUSION

The psychometric testing of the DigiFCC-P provided initial support for the convergent validity and reliability of the instrument. The instrument was also sensitive in detecting changes in the evaluations of FCC over time. However, there is a need for further development of the content validity of the instrument.

What is the lived experience of mothers in a Level-IV neonatal intensive care unit?

Rationale

Occupation-based practice in the neonatal intensive care unit may be impacted by a plethora of contextual factors. There is limited literature of the lived experience mothers have with mothering occupations for the care of premature infants in a Level-IV neonatal intensive care unit.

Methodology

A phenomenological design was used to interview mothers of premature infants in a Level-IV neonatal intensive care unit. The eight participants were mothers who had been in the neonatal intensive care unit for at least 1 month. Data was obtained via demographic form, two individual semi-structured interviews for each mother, and fieldnotes.

Results

Thematic analysis yielded five themes and two subthemes which were: unanticipated journey to becoming a mother, emotional rollercoaster, mother’s lost voice, subtheme cultural influences, roadblocks to mothering, unexpected layer to mothering occupations and subtheme support for mothering occupations. Each theme described a mother’s experience with mothering.

Conclusion

There is an importance for neonatal occupational therapists to provide support for mothering occupations for mothers from a variety of demographic and cultural backgrounds. Occupation-based practice in the neonatal intensive care unit continues to need attention for inclusion of all mothers. The findings showed that cultural humility should be practiced in family-centred care in the neonatal intensive care unit.

Maternal Perceptions About Sensory Interventions in the Neonatal Intensive Care Unit: An Exploratory Qualitative Study

BACKGROUND

Mothers play an important role in providing positive sensory experiences to their infants during NICU hospitalization. However, little is known regarding maternal perceptions about sensory-based interventions in the NICU. Further, understanding maternal perceptions was an important part of the process during development of the Supporting and Enhancing NICU Sensory Experiences (SENSE) program.

METHODS

Twenty mothers of very preterm infants were interviewed after NICU discharge and asked open-ended questions about sensory-based interventions they performed in the NICU and probed about their perceptions related to the development of a sensory-based guideline and the use of volunteers to provide sensory-based interventions when unable to be present in the NICU. Interviews were transcribed and uploaded into NVivoV.12 for content analysis.

RESULTS

Mothers reported that kangaroo care was a common sensory intervention they performed in the NICU. Of the 18 mothers who commented on the development of a sensory-based guideline, 17 (94%) said they would be accepting of one. Among 19 mothers, 18 (95%) supported volunteers conducting sensory-based interventions in their absence. Identified themes included: 1) Perceptions about development of a sensory-based guideline, 2) Perceptions of interactions with healthcare providers, 3) Maternal participation in sensory interventions, 4) Maternal experience, and 5) Emotions from mothers.

CONCLUSION

Maternal perceptions regarding the development of a sensory-based guideline were favorable, and the SENSE program has since been finalized after incorporating important insights learned from stakeholders in this study. Mothers' perceptions were tied to their NICU experiences, which elicited strong emotions. These findings highlight important considerations when developing family-centered interventions.

Measuring Parental Presence in the Neonatal Intensive Care Unit

Parental presence is believed to improve outcomes for infants hospitalized in the neonatal intensive care unit (NICU). As a result, NICU policies and procedures have evolved to support parental presence, and a growing number of studies examine the role of parental presence in the NICU. However, the measurement of parental presence is not standardized, complicating assessment of its impact on child and parent outcomes across studies. We reviewed 29 studies that presented 27 distinct methods of quantifying parental presence in the NICU and reported associations of presence with patient demographics, parental engagement in the NICU, and outcomes for both infants and parents. This overview provides a foundation for standardizing and improving routine measurement of parental presence in the NICU. KEY POINTS: · NICUs encourage visiting ill newborns.. · Measurement of presence is not standardized.. · A uniform method to assess presence is needed..

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.

Parents' pandemic NICU experience in the United States: a qualitative study

Background

Prior to the COVID-19 pandemic, parents of infants in the Neonatal Intensive Care Unit (NICU) frequently reported high levels of stress, uncertainty, and decreased parenting confidence. Early research has demonstrated that parents have had less access to their infants in the hospital due to restrictions on parental presence secondary to the pandemic. It is unknown how parents have perceived their experiences in the NICU since the beginning of the COVID-19 pandemic. The purpose of this study was to describe the lived experience of parents who had an infant in the NICU in the context of the COVID-19 pandemic to inform healthcare providers and policy makers for future development of policies and care planning.

Methods

The study design was a qualitative description of the impact of the COVID-19 pandemic on parents’ experiences of having an infant in the NICU. Free-text responses to open-ended questions were collected as part of a multi-method study of parents’ experiences of the NICU during the first six months of the pandemic. Participants from the United States were recruited using social media platforms between the months of May and July of 2020. Data were analyzed using a reflexive thematic approach.

Findings

Free-text responses came from 169 parents from 38 different states in the United States. Three broad themes emerged from the analysis: (1) parents’ NICU experiences during the COVID-19 pandemic were emotionally isolating and overwhelming, (2) policy changes restricting parental presence created disruptions to the family unit and limited family-centered care, and (3) interactions with NICU providers intensified or alleviated emotional distress felt by parents. A unifying theme of experiences of emotional distress attributed to COVID-19 circumstances ran through all three themes.

Conclusions

Parents of infants in the NICU during the first six months of the COVID-19 pandemic experienced emotional struggles, feelings of isolation, lack of family-centered care, and deep disappointment with system-level decisions. Moving forward, parents need to be considered essential partners in the development of policies concerning care of and access to their infants.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-03028-w.

Impact of the COVID-19 pandemic on developmental care practices for infants born preterm

OBJECTIVES

To assess the impact of the COVID-19 pandemic on rates of hospital visitation and rates and durations of developmental care practices for infants born preterm.

METHODS

We analyzed electronic medical record data from 129 infants born at less than 32 weeks gestational age (GA) cared for in the Lucile Packard Children's Hospital neonatal intensive care unit (NICU) in a COVID-19-affected period (March 8, 2020 to Nov 30, 2020, n = 67) and the analogous period in 2019 (n = 62). Rates of family visitation and of family- and clinical staff-delivered developmental care were compared across cohorts, adjusting for covariates.

RESULTS

Families of infants visited the hospital at nearly half of the rate during 2020 as during 2019 (p = 0.001). Infants experienced developmental care less frequently in 2020 vs. 2019 (3.0 vs. 4.3 activities per day; p = 0.001), resulting in fewer minutes per day (77.5 vs. 130.0; p = 0.001). In 2020, developmental care activities were 5 min shorter, on average, than in 2019, p = 0.001. Similar reductions occurred in both family- and staff-delivered developmental care. Follow-up analyses indicated that effects persisted and even worsened as the pandemic continued through fall 2020, despite relaxation of hospital visitation policies.

CONCLUSIONS

The COVID-19 pandemic has negatively impacted family visitation and preterm infant developmental care practices in the NICU, both experiences associated with positive health benefits. Hospitals should create programs to improve family visitation and engagement, while also increasing staff-delivered developmental care. Careful attention should be paid to long-term follow up of preterm infants and families.

[Untact Visit Service Development Based on an Application Reflecting the Circumstances during COVID-19: Focusing on Utilization in the Pediatric Intensive Care Units]

PURPOSE

This study aimed to develop an untact visit service based on an application that can be utilized in the pediatric intensive care unit (PICU) during COVID-19.

METHODS

This study adopted the double diamond process of service design comprising the discovery, defining, and development stages.

RESULTS

We developed an untact visit service based on an application that considered the child's status, schedule, photo, and video messages, and so on. Moreover, we derived a service flow regarding the required roles and the type of flow shown between each stakeholder.

CONCLUSION

Considering the ongoing pandemic, the untact visit service is designed to increase rapport and participation of parents, share the child's information in real-time, and provide one-stop service without increasing healthcare providers' work. It will be a useful visit service that can be applied and evaluated in various hospital settings and the PICU.

Randomized clinical trial investigating the effect of consistent, developmentally-appropriate, and evidence-based multisensory exposures in the NICU

OBJECTIVE

Evaluate the effect of a manualized multisensory program, applied across NICU hospitalization, on infant and parent outcomes.

STUDY DESIGN

Seventy parent-infant dyads (born ≤32 weeks gestation) in a Level IV NICU were randomized at birth to the multisensory program or standard-of-care. Parents in the multisensory group administered prespecified amounts of age-appropriate, evidence-based sensory interventions to their infants each day during NICU hospitalization according to the Supporting and Enhancing NICU Sensory Experiences (SENSE) program.

RESULTS

Infants who received the SENSE program had more lethargy on the NICU Network Neurobehavioral Scale (NNNS) (p = 0.05), even after controlling for medical and social risk (p = 0.043), and had higher Communication scores on the Ages and Stages Questionnaire (p = 0.04) at 1-year corrected age, but this relationship failed to reach significance after controlling for medical and social risk (p = 0.12).

CONCLUSION

The SENSE program shows promise for improving outcomes, but more research with larger sample sizes is needed.

Parental presence after significant procedures and medical events in the neonatal intensive care unit

PURPOSE

Very low birth weight (VLBW) and extremely preterm (EPT) infants typically experience multiple significant medical events, while in the neonatal intensive care unit (NICU), we aimed to identify how major medical and procedural events were associated with parental presence in this patient population.

MATERIALS AND METHODS

We retrospectively identified VLBW/EPT neonates at a single center and determined parental presence in the first 60 days of hospitalization based on routine documentation in the electronic medical record. The presence on each day was regressed on medical events and procedures occurring within the previous day using mixed-effects logistic regression.

RESULTS

The analysis included 174 infants contributing 8750 days (observations), including 6061 days (69%) with parental presence, and 607 days (7%) with major medical events or procedures. The occurrence of a medical event or procedure within the past day increased the odds of parental presence by 28% (odds ratio: 1.28; 95% confidence interval: 1.04, 1.57; p = .018). Further analysis found this association was limited to severe (versus moderate) events and procedures, and was absent when considering events over the past week (versus the past day).

CONCLUSIONS

Major medical events or procedures are associated with increased parental presence in the NICU. Future studies are needed to determine how interventions around the time of major medical events can support parental presence in the NICU and involvement in the child's care.

Caregiver Presence and Involvement in a Canadian Neonatal Intensive Care Unit: An Observational Cohort Study

BACKGROUND

Presence in the neonatal intensive care unit (NICU) is a vital step for caregivers initiating involvement, such as skin-to-skin contact, holding or singing/reading to their newborn. Little is known about caregiver presence and involvement in Canadian NICU's context by caregiver type (mother, father, other), and the association between maternal presence and key maternal and newborn characteristics.

PURPOSE

The primary objective was to examine the presence and involvement of family caregivers in the NICU. The secondary objective was to examine the relationship between maternal presence and maternal and newborn characteristics.

DESIGN AND METHODS

A prospective observational cohort study in an open bay setting of an Eastern Canadian NICU. Presence (physically present at the newborn's bedside) and involvement (e.g., skin-to-skin, singing/reading) were tracked daily by families in the NICU until discharge. Demographic information was also collected.

RESULTS

Participants included 142 mothers and their newborns. Mothers were present 8.7 h/day, fathers were present 4.1 h/day, and other caregivers were present 1.8 h/day in the NICU in the first 34 days. Mothers were involved in care activities 50% of the time they were present in the NICU, whereas fathers and other caregivers were spending 20% and 6% of their time respectively. Regression identified maternal age, distance to home, parity, birthweight, and length of stay to be statistically significant variables related to maternal presence.

CONCLUSIONS

There is variation in presence and involvement by caregiver type. Targeted interventions to maintain and increase mothers, fathers and other caregivers' presence and involvement in care throughout their stay in the NICU are recommended.

Mapping the Field in Stress, Anxiety, and Postpartum Depression in Mothers of Preterm Infants in Neonatal Intensive Care

Objective: The main aim of this study was to describe and conduct a bibliometric analysis of the state of research on stress, anxiety, and postpartum depression in mothers of preterm infants in the Neonatal Intensive Care Unit. Background: Women affected by premature births are particularly exposed to mental health difficulties in the postpartum period. The desire to comprehend and the growing interest in research on stress, anxiety, and postpartum depression in mothers of preterm infants in neonatal intensive care have led to a substantial rise in the number of documents in this field over the last years. Thus, it makes it vital to regularly review the state of knowledge on this phenomenon in order to identify progress and constraints, to stimulate reflection, and to encourage progress in future research. Method: This study examined 366 articles published in the Scopus database (1976–2020). Keyword analysis was also used to identify hot research trends to be developed in future studies. This study complies with the PRISMA-Scr guidelines for quality improvement research in the EQUATOR network. Results: Our results reveal that research in this field is in a period of high production and allows this flourishing body of work to be organized into different periods, highlighting the most important themes. In such a way, our research enriches the lively field by presenting a comprehensive understanding of the field. Discussion: The key contribution of this study is the development of a conceptual map of research on stress, anxiety, and postpartum depression in mothers of preterm infants in neonatal intensive care units.

Parents Matter: Examination of Family Presence in the Neonatal Intensive Care Unit

OBJECTIVE

The aim of this study is to examine presence trends for parents and family members during an infant's Neonatal Intensive Care Unit (NICU) hospitalization.

STUDY DESIGN

We conducted a review of 386 infants hospitalized in a Level IV NICU in the Northwestern United States between June 2013 and April 2014 to quantitatively examine presence trends.

RESULTS

Infants were visited by multiple family members. The father was the most common first family member at the bedside after admission. Parents were present over half of the days their infants were in the NICU (medians: mothers 75% and fathers 59%), but a relatively small percentage of the total hospitalization time (medians: 10% mothers and 5% fathers). Fathers', grandmothers', and grandfathers' presence with their infants in the NICU were negatively correlated with infants' total length of stay in the NICU. This finding was not replicated for mothers. Female family members were present in the NICU more than male family members.

CONCLUSION

Parents are present a small percent of the time their infants are hospitalized in the NICU. NICU based methods to improve family presence may lead to improved patient and family centered care.

KEY POINTS

· Mothers are present 10% of total NICU time.. · Fathers are present 5% of total NICU time.. · Fathers' presence was associated with a shorter stay.. · Grandparents' presence was associated with a shorter stay.. · Females were present significantly more than males..

Support provided by healthcare professionals to the mothers of newborns in the neonatal unit

Objective: To evaluate the support offered by health professionals to mothers of newborns admitted to the neonatal unit.Methods: Descriptive cross-sectional study with a quantitative approach conducted at the Regional Hospital of Tucuruí, in the state of Pará, region of the Brazilian Amazon, where 33 mothers who had newborn children admitted to the neonatal unit responded to the structured adapted version of the NPST (Nurse Parent Support Tool ). Results: Most were aged 20-34 years (48%), married or in a stable relationship (69%), multiracial (87%), housewife (57%), with up to 11 years of study (72%). The scores for the NPST subdomains were 3.39 ± 1.65 (Communication and Information Support), 4.13 ± 1.33 (Emotional Support), 3.93 ± 1.46 (Incentive Support), and 4.21 ± 1,27 (Instrumental Support). The findings revealed unsatisfactory communication and information support from health professionals to mothers, although they expressed satisfaction with the care provided. Conclusions: The perception of scarcity of human resources and health education, verified in this study, weakens the communication process during hospitalization and influences the mother's well-being, leading to a decrease in the efficiency of the support provided. The improvement in this area can lead to better results in daily practice. The replication of this study to other locations can lead to more significant assistance to mothers of hospitalized neonates and provide new technologies and strategies in health education.

When can I hold my baby? An audit of time to first cuddle for preterm babies (<32 weeks) pre introduction and post introduction of a Family-Integrated Care model

AIM

The audit examined time to first cuddle between preterm babies (born < 32 weeks) and their parent pre- and post-introduction of a family-integrated care model. Secondary outcomes included time to full feeds and length of neonatal intensive care stay.

BACKGROUND

Parental separation due to neonatal intensive care unit admission is known to negatively affect parental and baby wellbeing.

DESIGN

A "before-after" design compared outcomes for babies admitted pre- (2015) and post (2018)-implementation of the model in a Western Australian neonatal intensive care unit.

METHODS

A retrospective medical record audit included babies from two gestational age groups in 2015 and 2018, born ≤27 + 6 weeks and 28-31 + 6 weeks. SQUIRE checklist guided reporting of the audit.

RESULTS

One hundred fifty-three babies were included in the audit, 79 from 2015 (≤27 + 6 weeks n = 39 and 28-31 + 6 weeks n = 40) and 74 from 2018 (≤27 + 6 weeks n = 35 and 28-31 + 6 weeks n = 39). Babies in both years were born at similar median gestational ages with comparable birthweights. Babies born ≤27 + 6 weeks in 2018 were cuddled earlier (median = 141 h old) compared with those in 2015 (median = 157 h old). Median time to reach full feeds decreased and was significant in the ≤27 + 6-week group: 288 h (12 days) in 2015 to 207.5 h (8.6 days) in 2018. Length of stay was longer for the ≤27 + 6-week gestation 2018 group (median = 64 days) and 28-31 + 6-week gestation 2018 group (median = 22 days).

CONCLUSION

Family-integrated care models may decrease the time to first cuddle and full feeds. Further research on outcomes such as breastfeeding, infant weight gain and length of stay can extend existing knowledge.

RELEVANCE TO CLINICAL PRACTICE

Family-integrated care models may offer benefits to families of hospitalised preterm babies and investigating barriers to its implementation and creation of solutions to overcome barriers warrants attention.

Implementing a Skin-to-Skin Care and Parent Touch Initiative in a Tertiary Cardiac and Surgical Neonatal Intensive Care Unit

BACKGROUND

Skin-to-skin care (SSC) has been integrated as an essential component of developmental care for preterm infants. Despite documented benefits, SSC is not routinely practiced in the cardiac and surgical neonatal intensive care unit, with a predominantly term population, due to staff apprehension, patient factors and acuity, and environmental constraints.

PURPOSE

The purpose of this quality improvement project was to increase SSC, parental holds, and parent touch events for infants in our cardiac and surgical neonatal intensive care unit. When traditional SSC was not possible, alternative holds and alternative parent touch (APT) methods were encouraged.

METHODS

Quality improvement and qualitative descriptive methodology were utilized to assess baseline, develop education and practice changes, and evaluate the use of SSC, holds, and APT methods at 12 and 18 months postintervention. Implementation included educational tools and resource development, simulations, peer champions, in-class teaching, and team huddles. Decisions around the type of hold and parent touch were fluid and reflected complex infant, family, staff, and physical space needs.

FINDINGS

Given its initial scarcity, there was an increased frequency of SSC and variety of holds or APT events. Staff survey results indicated support for the practice and outlined persistent barriers.

IMPLICATIONS FOR PRACTICE

Skin-to-skin care, holds, and APT practices are feasible and safe for term and preterm infants receiving highly instrumented and complex cardiac and surgical care.

IMPLICATIONS FOR RESEARCH

Future research regarding the intervention's impact on neurodevelopmental outcomes of infants and on parent resilience in the surgical and cardiac neonatal intensive care unit is warranted.

Applying the RE-AIM framework to evaluate the implementation of the Supporting and Enhancing NICU Sensory Experiences (SENSE) program

Background

To maximize the benefit of parent-directed, positive sensory exposures in the NICU, a structured sensory-based program titled the Supporting and Enhancing NICU Sensory Experiences (SENSE) program was developed that includes specific doses and targeted timing of evidence-based sensory exposures.

Methods

The Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework was used to systematically evaluate the SENSE program as an implementation strategy. One-hundred preterm infants ≤32 weeks gestation were studied (61 receiving the SENSE program and 39 standard-of-care). Parent education time and infant sensory exposures were tracked, and parents completed a questionnaire that probed their perceptions about the SENSE program.

Results

One-hundered thirty-one families were recruited, and 100 (76%) enrolled. The SENSE program was initiated at an average postmenstrual age of 29.8 (±2.4) weeks; 4.9 (±5.6) days after birth. The average number of education sessions with families was 4.8 (±3.7) amounting to 72.3 (±37.4) total minutes over hospitalization. The total time of logged tactile and auditory exposures among SENSE recipients over the length of hospitalization was a median (IQ range) of 9325 (5295-15,694) minutes over an average of 10.1 (±7.6) weeks of hospitalization. There were differences in the proportion of tactile and auditory exposure targets received by the infant among those receiving the SENSE program compared to standard-of-care (91% compared to 48%; p < 0.0001). Ninety-five percent of infants tolerated the SENSE program as defined, with 5% of infants requiring intermittent adaptations or the interventions being stopped for a period that typically lasted 1–2 weeks. Earlier parent education was related to more parent participation in SENSE program interventions (p = 0.04). Eighty-five percent of participants receiving the SENSE program had most of the sensory interventions completed by parents, as opposed to the medical or sensory support team. Seventy-two percent of infants had at least 100% of the auditory and tactile doses conducted over the length of stay. Parents reported acceptability.

Conclusion

The SENSE program had good reach, was effective and acceptable with minimal cost, was adopted, and had good fidelity. Insights from implementation of the SENSE program (within a research study) informed future strategies to aid maintenance during dissemination.

Increasing Skin-to-Skin in a Level IV NICU: A Quality Improvement Project

PURPOSE

To evaluate the effect of a bundled intervention on the number of skin-to-skin ("kangaroo care") events occurring in a level IV NICU.

DESIGN

A quality improvement effort centering around the introduction of an intervention bundle intended to safely increase the rate of skin-to-skin holding. Rates of unplanned extubations were recorded as a balancing measure to estimate safety.

SAMPLE

All infants admitted to the NICU from December 2017 through September 2019 were included. The "preintervention" period was the 6 months prior to the initiation of the intervention bundle (December 2017-May 2018).

RESULTS

The absolute number of skin-to-skin holds increased from the preintervention phase (range 7-28 holds/month, median 11 holds/month) to the postintervention phase (range 16-100 holds/month, median 55 holds/month). The total unplanned extubations showed no significant change between the preintervention and postintervention periods.

The burden of early life stress on the nociceptive system development and pain responses

For a long time, the capacity of the newborn infant to feel pain was denied. Today it is clear that the nociceptive system, even if still immature, is functional enough in the newborn infant to elicit pain responses. Unfortunately, pain is often present in the neonatal period, in particular in the case of premature infants which are subjected to a high number of painful procedures during care. These are accompanied by a variety of environmental stressors, which could impact the maturation of the nociceptive system. Therefore, the question of the long-term consequences of early life stress is a critical question. Early stressful experience, both painful and non-painful, can imprint the nociceptive system and induce long-term alteration in brain function and nociceptive behavior, often leading to an increase sensitivity and higher susceptibility to chronic pain. Different animal models have been developed to understand the mechanisms underlying the long-term effects of different early life stressful procedures, including pain and maternal separation. This review will focus on the clinical and preclinical data about early life stress and its consequence on the nociceptive system.

Inpatient Unit Leaders' Perspectives on Parent Engagement in Neonatal and Pediatric Intensive Care: A Secondary, Qualitative Analysis

BACKGROUND

Hospital unit leaders help set the unit's priorities and are responsible for guiding the unit mission and philosophy of care; however, the perspective of leaders in facilitating parent engagement within intensive care units is limited.

PURPOSE

The purpose of this study was to explore how medical and nursing unit leaders facilitate parent engagement in intensive care settings.

METHODS

Qualitative secondary analysis of 16 semistructured interviews of unit leadership (medical directors and nurse managers). Directed content analysis explored themes within the interviews using systematic strategies to ensure rigor.

FINDINGS

Unit leadership described 3 main features of care delivery necessary for supporting parent engagement: (1) culture of care, (2) relationships in care, and (3) environment of care. Communication among providers and parents and timing of decision-making were key areas addressed, along with concerns about physical space limiting parent engagement. Unit leaders discussed how the 3 main features (unit culture, relationships, and physical space) of care delivery were interconnected to optimize parent engagement.

IMPLICATIONS FOR PRACTICE

Overall, unit leaders recognized the importance of each feature of care delivery in facilitating engagement. Parent engagement is ultimately influenced by the optimization of delivering inclusive care: the physical space, the policies surrounding medical and nursing care, and the overall culture of the unit.

IMPLICATIONS FOR RESEARCH

Future research needs to explore best practices around relationship building and managing space limitations. Further clarification of the needs and expectations of both parents and providers surrounding parent engagement in intensive care settings is needed.

Prevalence of Acute Rehabilitation for Kids in the PICU: A Canadian Multicenter Point Prevalence Study

OBJECTIVES

To evaluate mobilization practices, barriers, and mobility-related adverse events in Canadian PICUs.

DESIGN

National 2-day point prevalence study.

SETTING

Thirteen PICUs across Canada.

PATIENTS

Children with a minimum 72-hour PICU length of stay on the allocated study day.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Outcomes of interest were the prevalence and nature of mobilization activities, rehabilitation resources, adverse events, and factors associated with out-of-bed mobility and therapist-provided mobility. Two PICUs (15%) had early mobilization practice guidelines, and one PICU (8%) reported a formal process for engaging families in the mobilization of patients. The prevalence of mobilization was 110 of 137 patient-days (80%). The commonest activity was out-of-bed mobility (87/137; 64% patient-days); there was no active mobilization on 46 patient-days (34%). Therapists provided mobility on 33% of patient-days. Mobility was most commonly facilitated by nurses (74% events) and family (49% events). Family participation was strongly associated with out-of-bed mobility (odds ratio 6.4; p = 0.001). Intubated, mechanically ventilated patients were mobilized out-of-bed on 18 of 50 patient-days (36%). However, the presence of an endotracheal tube, vasoactive infusions, and age greater than or equal to 3 years were independently associated with not being mobilized out-of-bed. Barriers were reported on 58 of 137 patient-days (42%), and adverse events occurred in 22 of 387 mobility events (6%).

CONCLUSIONS

Mobilization is common and safe, and the majority of children in Canadian PICUs are being mobilized out-of-bed, even when mechanically ventilated. Family engagement in PICU-based rehabilitation is increasing. This study provides encouraging evidence that common barriers can be overcome in order to safely mobilize children in PICUs.

Effectiveness of the Close Collaboration with Parents intervention on parent-infant closeness in NICU

BACKGROUND

Parent-infant closeness during hospital care of newborns has many benefits for both infants and parents. We developed an educational intervention for neonatal staff, Close Collaboration with Parents, to increase parent-infant closeness during hospital care. The aim of this study was to evaluate the effectiveness of the intervention on parent-infant closeness in nine hospitals in Finland.

METHODS

Parents of hospitalized infants were recruited in the hospitals during 3-month periods before and after the Close Collaboration with Parents intervention. The data were collected using daily Closeness diaries. Mothers and fathers separately filled in the time they spent in the hospital and the time of skin-to-skin contact with their infant during each hospital care day until discharge. Statistical analyses were done using a linear model with covariates.

RESULTS

Diaries were kept before and after the intervention by a total of 170 and 129 mothers and 126 and 84 fathers, respectively. Either parent was present on average 453 min per day before the intervention and 620 min after the intervention in the neonatal unit. In the adjusted model, the increase was 99 min per day (p = 0.0007). The infants were in skin-to-skin contact on average 76 min per day before the intervention and 114 min after the intervention. In the adjusted model, skin-to-skin contact increased by 24 min per day (p = 0.0405).

CONCLUSION

The Close Collaboration with Parents intervention increased parents' presence and skin-to-skin contact in nine hospitals. This study suggests that parent-infant closeness may be one mediating factor explaining benefits of parenting interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04635150 . Retrospectively registered.

Effects of single family room architecture on parent-infant closeness and family centered care in neonatal environments-a single-center pre-post study

OBJECTIVE

The aim of this study was to evaluate the effects of a single family room architecture in a neonatal intensive care unit (SFR-NICU) on parents' presence, parent-infant skin-to-skin contact (SSC) and the quality of family centered care.

STUDY DESIGN

Two cohorts of parents of preterm infants were compared: those in the unit before and after the move to SFR-NICU. The parents used daily diaries to report their presence and SSC, and they responded to daily text message questions about the quality of family centered care.

RESULTS

Parents spent more time in the SFR-NICU, but no significant change was found in SSC. Parents rated the quality of family centered care highly in both unit architectures, without a change in rating after the move.

CONCLUSION

The SFR-NICU increased parents' presence but not SSC. The change in architecture did not affect parents' evaluations of the quality of family centered care, which was already highly rated before the move.

Care of hospitalized infants and their families during the COVID-19 pandemic: an international survey

This research study explored changes in family-centered care practices for hospitalized infants and families due to the COVID-19 pandemic. This exploratory descriptive study used a 49-item online survey, distributed to health care professionals working with hospitalized infants and families. The sample consisted of 96 participants from 22 countries. Prior to the COVID-19 pandemic, 87% of units welcomed families and 92% encouraged skin-to-skin care. During the pandemic, family presence was restricted in 83% of units, while participation in infant care was restricted in 32%. Medium-sized (20-40 beds) units applied less restriction than small (<20 beds) units (p = 0.03). Units with single-family rooms that did not restrict parental presence, implemented fewer restrictions regarding parents' active participation in care (p = 0.02). Restrictions to families were not affected by geographic infection rates or developmental care education of health care professionals. Restrictions during the pandemic increased separation between the infant and family.

The lived experiences of critically ill infants hospitalised in neonatal intensive care: A scoping review

BACKGROUND

Neonatal intensive care saves lives, but the environment in which this occurs is complex and has been shown to negatively disrupt some aspects of an infant's early development. Identifying these negative effects has relied on measuring physiological and behavioural responses. Little research has sought to understand and learn from what an individual infant can communicate about their lived experience.

AIM

To examine what is known of the lived experiences of infants hospitalised in neonatal intensive care.

STUDY DESIGN

A scoping review using the revised Arksey and O'Malley framework was undertaken. Relevant studies, exploring an infant's experience of hospitalisation were identified through a comprehensive, systematic literature search.

RESULTS

4955 articles were retrieved, 88 full texts reviewed, and 23 studies included. We identified no studies that assessed the experience from the infant's perspective. The infant experience was explored using quantitative methodology, characterising, and describing the experience in measurable physiological, behavioural, and neurodevelopmental terms or through the lens of medical outcomes. The environment is described as too loud and too bright and infants are exposed to high levels of medical handling, impacting on physiology, behaviour, sleep, feeding, and both short- and longer-term outcomes.

CONCLUSION

The studies captured in this review focused on quantitative, measurable outcomes as a proxy for the experience as it might be felt, interpreted, and processed by an infant. Medical focus has been crucial to advance the field of neonatology, but the review highlights an important gap; the need to explore and better understand the infant's experience through their eyes.

Impact of the COVID-19 pandemic on developmental care practices for infants born preterm

OBJECTIVES

To assess the impact of the COVID-19 pandemic on rates of hospital visitation and rates and durations of developmental care practices for infants born preterm delivered by both families and clinical staff.

METHODS

We analyzed electronic medical record data from infants born at less than 32 weeks gestational age (GA) cared for in the Lucile Packard Children's Hospital neonatal intensive care unit (NICU) in a COVID-19-affected period (March 8, 2020 to May 31, 2020) and the analogous period in 2019. Our final sample consisted of 52 infants ( n =27, 2019 cohort; n =25, 2020 cohort). Rates of family visitation and of family- and clinical staff-delivered developmental care were compared across cohorts, adjusting for GA at start of study period.

RESULTS

Results indicated that families of infants in the 2020 cohort visited less frequently (47% of available days) than those in the 2019 cohort (97%; p =0.001). Infants received developmental care activities less frequently in the 2020 cohort (3.51 vs. 4.72 activities per day; p =0.04), with a lower number of minutes per day (99.91 vs. 145.14; p =0.04) and a shorter duration per instance (23.41 vs. 29.65; p =0.03). Similar reductions occurred in both family- and staff-delivered developmental care activities.

CONCLUSIONS

The COVID-19 pandemic has negatively impacted family visitation and preterm infant developmental care practices in the NICU, both experiences associated with positive health benefits. Hospitals should create programs to improve family visitation and engagement, while also increasing staff-delivered developmental care. Careful attention should be paid to long-term follow up of preterm infants and families.