Parents' presence and parent-infant closeness in 11 neonatal intensive care units in six European countries vary between and within the countries

Optimal presence: enhancing parent integration to maximize neurodevelopmental outcomes in preterm infants

Preterm birth disrupts the natural progression of events in the parent-infant relationship and bestows many of the typical parent responsibilities to the clinical care team. In turn, the neonatal intensive care environment (NICU) introduces obstacles to parents that would not otherwise be encountered and forces parents to adapt to this artificial environment as they seek to bond with and care for their newborn. Facilitating parent presence at the bedside and incorporating them into the care of their preterm infant is critical for lessening the immediate burden to both the parent and offspring while also ensuring the best possible outcome for preterm infants. In this review, we explore the impact that parents exert on the neurodevelopmental outcome of preterm infants and identify several barriers and facilitators to parent presence.

Family-centred care interventions in neonatal intensive care units: a scoping review of randomised controlled trials providing a menu of interventions, outcomes and measurement methods

BACKGROUND

Benefits of different types of family-centred care (FCC) interventions in neonatal intensive care units (NICUs) have been reported. However, a comprehensive review of existing FCC intervention studies was lacking.

OBJECTIVE

This review aimed at synthesising the characteristics of FCC interventions, related outcomes and measurement methods in randomised controlled trials (RCTs) in NICU, and providing menus of options to favour implementation and further research.

METHODS

We searched PubMed, EMBASE, Web of Science and the Cochrane Library up to 31 January 2022. Interventions were mapped according to five categories as defined by a previous Cochrane review. We described outcome types, measurement populations, measurement methods and timelines. Subgroup analyses were also performed.

RESULTS

Out of 6583 studies identified, 146 met eligibility criteria. Overall, 52 (35.6%) RCTs tested more than one category of intervention, with a large variety of combinations, with the most frequent category of intervention being the educational (138 RCTs, 94.5%). We identified a total of 77 different intervention packages, and RCTs comparing the same interventions were lacking. The 146 RCTs reported on 425 different outcomes, classified in 13 major categories with parental mental health (61 RCTs, 41.8% of total RCTs) being the most frequent category in parents, and neurobehavioural/developmental outcomes being the most frequent category in newborns (62 RCTs, 42.5%). For several categories of outcomes almost every RCT used a different measurement method. Educational interventions targeting specifically staff, fathers, siblings and other family members were lacking or poorly described. Only one RCT measured outcomes in health workers, two in siblings and none considered other family members.

CONCLUSIONS

A large variety of interventions, outcomes and measurement methods were used in FCC studies in NICU. The derived menus of options should be helpful for researchers and policy makers to identify interventions most suitable in each setting and to further standardise research methods.

The effect of developmental care on the length of hospital stay and family centered care practice for very low birth weight infants in neonatal intensive care units: A cluster randomized controlled trial

BACKGROUND

Despite previous studies suggesting that developmental care can provide benign stimulation to promote neural development of newborns, more evidence is needed regarding the other clinical benefits of developmental care.

OBJECTIVE

To evaluate the effect of implementing developmental care on the length of hospital stay, the improvement of care practice in neonatal intensive care units, as well as the short-term outcome of very low birth weight infants.

DESIGN

Cluster-randomized controlled trial.

SETTING(S) AND PARTICIPANTS

From March 1, 2021 to March 1, 2022, 1400 very low birth weight infants were recruited from 14 tertiary neonatal intensive care units in China.

METHODS

We assigned 14 neonatal intensive care units to either developmental care or standard care. The length of hospital stay of the infants was the primary outcome analyzed at the individual level. Secondary outcomes were family centered care practice including parental involvement, the skin to skin care, exclusive breast milk, oral immune therapy and breastfeeding. The environmental management (noise and light) and the short-term outcomes were also evaluated.

RESULTS

The length of hospital stay for the developmental care group was 65 % as long as that for the control group (HR: 0.65, 95 % CI, 0.451-0936, p = 0.021). After controlling the covariables, the adjusted HR = 0.755 (95 % CI, 0.515 to 1.107, p = 0.150). When compared to the control group, the developmental care group had greater access to SSC, with 22 infants (3.8 %) in the developmental care group compared to 13 infants (1.7 %) in the standard care group (p = 0.013). A greater proportion of infants in the developmental care group were fed at the breast, than those in the standard care group (136 [23.6 %] vs 9 [1.1 %]; p = 0.029). Compared to the control group, exclusively breast milk was significantly more favorable in the developmental care group (435 [75.6 %] vs 114 [15.0 %]; p = 0.001). The difference remained significant even after adjusting for covariates. However, the rate of oral immune therapy and parental involvement was similar in the two groups. The average noise and light levels in the developmental care group were significantly lower than those in the standard care group. After adjusting for confounders, the difference remained significant. There were no significant differences among groups in the mortality and major morbidity.

CONCLUSIONS

Developmental care might have developed an accumulated effect over time on the length of hospital stay among very low birth weight infants. The implementation of developmental care can greatly improve family centered care practices and the neonatal intensive care unit environment.

REGISTRATION

ClinicalTrials.govNCT05166720. Registration date: 1 March, 2021.

New policies on skin-to-skin contact warrant an oxytocin-based perspective on perinatal health care

Background

In 2023, the World Health Organization (WHO) published a Global Position Paper on Kangaroo Mother Care (KMC), which is applicable to all countries worldwide: from the moment of birth, every "small and sick" newborn should remain with mother in immediate and continuous skin-to-skin contact (SSC), receiving all required clinical care in that place. This was prompted by the startling results of a randomized controlled trial published in 2021: in which 1,609 infants receiving immediate SSC were compared with 1,602 controls that were separated from their mothers but otherwise received identical conventional state-of-the-art care. The intervention infants showed a 25% reduction in mortality after 28 days.

New perspectives

The new WHO guidelines are a significant change from earlier guidance and common clinical practice. The author presents that separating mothers and babies is assumed to be "normal" (a paradigm) but actually puts newborns at increased risk for morbidity and mortality. The author presents arguments and ethical perspectives for a new perspective on what is "normal," keeping newborns with their mothers is the infant's physiological expectation and critical requirement for healthy development. The author reviews the scientific rationale for changing the paradigm, based on synchronous interactions of oxytocin on both mother and infant. This follows a critique of the new policies that highlights the role of immediate SSC.

Actionable recommendations

This critique strengthens the case for implementing the WHO guidelines on KMC for small and sick babies. System changes will be necessary in both obstetric and neonatal settings to ensure seamless perinatal care. Based on the role of oxytocin, the author identifies that many current routine care practices may actually contribute to stress and increased vulnerability to the newborn. WHO has actionable recommendations about family involvement and presence in newborn intensive care units.

Discussion

The concepts of resilience and vulnerability have specific definitions well known in perinatal care: the key outcome of care should be resilience rather than merely the absence of vulnerability. Newborns in all settings and contexts need us to re-evaluate our paradigms and adopt and implement the new WHO guidelines on KMC in perinatal care.

Observational study showed that using video consultations was a viable way of delivering an early discharge programme for preterm infants

AIM

The aim of this study is to evaluate an early discharge programme with video consultations for preterm infants.

METHODS

A homecare programme for preterm infants was developed. Prospective data on readmissions, length of stay, growth, breastfeeding rates, and parent self-reports about satisfaction were collected from April 2021 to August 2023. Additionally, retrospective data were collected from the Norwegian Neonatal Network Central Database from 2020.

RESULTS

Preterm infants, 72 and parents, 128 were included. The infants were discharged from the hospital at a median of 35 + 6 (34 + 0-42 + 4) weeks postmenstrual age. The median length of stay in the program was 18 days (3-37). There were four readmissions. The Z-score of infant weight slightly increased during the follow up, with a mean of 0.16. By discharge, 75% of the infants were exclusively breastfed. Growth and breastfeeding rates were in line with retrospective data (85 infants). The response rate of the parents to the survey was 61 (52%). Overall, the parents (n = 54) were highly satisfied (96%). The video consultations contributed to ensuring parents to feel safe in caring for their infant at home.

CONCLUSION

Follow up by video consultations is a viable healthcare service for preterm infants, the infants' growth is sufficient, breastfeeding rates are maintained, and parents feel safe and satisfied.

Evaluation of a new tool - "Step by step with my baby" - to support parental involvement in the care of preterm infants

BACKGROUND AND AIMS

Parental guidance is essential for supporting parental involvement, maintaining the quality and safety of infant care, and limiting parental stress. The efficiency of a new tool to support parental empowerment - "Step by step with my baby" - was evaluated. The perception of this tool by parents and nurses was studied.

METHODS

This was a prospective, observational study conducted from September 2019 to December 2020 at a level-3 neonatal center. A total of 79 newborns (<33 weeks of gestational age or small for gestational age), 84 parents, and 94 nurses were included. The new tool that was evaluated is in the form of a drawing of flowers to be colored according to the parents' ability to care for their newborn. Six domains were explored and given a score (total of 35 points) according to the parents' ability to care for each item: behavior, skin-to-skin contact, carrying, oral and tube feeding, and routine care. The use and relevance of this tool were evaluated by parents and caregivers.

RESULTS

At a mean of 19 days of life, parents required caregiver support regardless of the skill domain (6/35). After 26 days, the mean score increased to 19.4 (p < 0.05). Parents felt autonomous in changing diapers and monitoring temperature but always required help for skin-to-skin contact, carrying, and feeding with or without a tube. The progression was not affected by the presence of siblings, the distance from home, and staying in the parental hospital room. For 67 % of the parents, the tool gave them a better understanding of their newborn and helped them be more confident (69 %) without feeling judged (81 %). These feelings were upheld by nurses.

CONCLUSIONS

This tool was efficient for evaluating parents' autonomy and helped them take ownership of the care provided.

Parental presence, participation, and engagement in paediatric hospital care: A conceptual delineation

AIM

To delineate between the concepts of parental presence, participation, and engagement in paediatric hospital care.

DESIGN

The concepts' uses in the literature were analysed to determine attributes, influences, and relationships.

METHODS

Delineations of each concept are established and conceptual definitions are proposed following Morses' methods.

DATA SOURCES

MEDLINE (PubMed); CINAHL, PsycINFO, Sociology Source Ultimate (EBSCOhost); Embase, Scopus (Elsevier); Google Scholar. Search dates October 2021, February 2023.

RESULTS

Multinational publications dated 1991-2023 revealed these concepts represent a range of parental behaviours, beliefs, and actions, which are not always perceptible to nurses, but which are important in family-integrated care delivery. Parental presence is the state of a parent being physically and/or emotionally with their child. Parental participation reflects parents' performing caregiving activities with or without nurses. Parental engagement is a parents' state of emotional involvement in their child's health and the ways they act on their child's behalf.

CONCLUSION

These concepts' manifestations are important to parental role attainment but may be inadequately understood and considered by healthcare providers.

IMPLICATIONS

Nurses have influence over parents' parental presence, participation, and engagement in their child's care but need support from healthcare institutions to ensure equitable family-integrated care delivery.

IMPACT

Problem: Lack of clear definition among these concepts results in incomplete and at times inequitable family-integrated care delivery.

FINDINGS

Parental presence is an antecedent to parental participation, and parental presence and participation are elements of parental engagement. The concepts interact to influence one another.

IMPACT

Hospitalized children, their families, nurses, and researchers will benefit through a better understanding of the concepts' attributes, interactions, and implications for enhanced family-integrated care delivery.

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.

Associations between Parental Engagement in the Neonatal Intensive Care Unit and Neighborhood-Level Socioeconomic Status

OBJECTIVE

 This study aimed to (1) determine the effect of neighborhood-level socioeconomic status (SES), which considers the social and physical environment where a person lives, on parental engagement in the Neonatal Intensive Care Unit (NICU) and (2) compare the relationships between parental engagement and individual versus neighborhood-level measures of SES.

STUDY DESIGN

 In this cohort study, parents (n = 45) of premature neonates ≤34 weeks' gestation were assessed at 2 and 6 weeks after birth from December 2017 to October 2019. Neighborhood-level SES was determined using census data per the Association of Maternal and Child Health Programs' methodology, and parents self-reported their education level as an individual-level measure of SES. Data on frequency of engagement in NICU activities, including telephone updates, visitation, providing expressed breastmilk, and participating in kangaroo care, were collected from the electronic medical record. Parent psychosocial factors were assessed using validated surveys. Statistical analysis was performed using Fisher's exact test, t-test, and logistic regression.

RESULTS

 In multivariate regression analysis, disadvantaged neighborhood-level SES was associated with decreased odds of kangaroo care (OR = 0.16, 95% CI: [0.03-0.89]) and visitation (OR = 0.14, 95% CI: [0.02-0.87]), while lower individual-level SES was not significantly associated with kangaroo care, visiting, calling, or pumping (p > 0.05).

CONCLUSION

 Parental engagement was more consistently and significantly associated with neighborhood-level SES than with individual-level SES. Therefore, neighborhood-level SES measures may be more explanatory than individual-level SES measures. Further studies and targeted interventions are needed to address disparities in the frequency of kangaroo care and visitation according to SES.

KEY POINTS

· Parents from disadvantaged neighborhoods are less likely to do kangaroo care and visit the NICU.. · Parent engagement was more significantly associated with neighborhood than with parent education.. · Neighborhood-level SES measures may be more explanatory than individual-level SES measures.. · Interventions are needed to address SES-related disparities in NICU kangaroo care and visitation..

Parents' and neonatal healthcare professionals' views on barriers and facilitators to parental presence in the neonatal unit: a qualitative study

BACKGROUND

Parent and infant separation in the neonatal unit is associated with adverse health outcomes. Family-integrated care has several advantages and the potential to reduce these adverse outcomes but requires parental presence. This study aimed to explore the views of parents and neonatal healthcare professionals (nHCPs) on barriers and facilitators to parental presence in a Swiss neonatal unit and to identify possible differences between nHCPs and parents, and between mothers and fathers.

METHODS

Data were collected through semi-structured interviews with parents and focus group discussions with nHCPs. Inductive content analysis was used to identify barriers and facilitators to parental presence in the neonatal unit.

RESULTS

Twenty parents (10 mothers and 10 fathers) and 21 nHCPs (10 nurses and 11 physicians) participated in the study. Parents and nHCPs experienced barriers and facilitators related to: (1) Structural factors of the institution, such as infrastructure or travel and distance to the neonatal unit. (2) Organization and time management of parental presence, daily activities, and work. (3) Resources, which include factors related to the legal situation, support services, family, and friends. (4) Physical and psychological aspects, such as pain, which mainly affected mothers, and aspects of emotional distress, which affected both parents. Self-care was an important physical and psychological facilitator. (5) Parent-professional interaction. Parental presence was influenced by communication, relationship, and interaction in infant care; and (6) Cultural aspects and language. Some perspectives differed between mothers and fathers, while the overall views of parents and nHCPs provided complementary rather than conflicting insights. Using visit plans to support the organization, educating nHCPs in knowledge skills and available resources to improve encouragement and information to parents, strengthening parent self-care, and improving nHCPs' attitudes towards parental presence were seen as possible improvements.

CONCLUSIONS

Multifactorial barriers and facilitators determine parental presence and experience in the neonatal unit. Parents and nHCPs made specific recommendations to improve parental presence.

Neonatal family-centered care: evidence and practice models

Although advances in neonatology have reduced the mortality rate of high-risk infants, sick newborns or pre-mature infants undergo more intensive monitoring, pain-ful procedures, and lengthy hospitalization, leading to pro-longed separation from their parents. In recent decades, the importance of parent-infant closeness early in life has become more apparent, especially in preterm infants who are prone to neurodevelopmental deficits. There is an increasing body of evidence regarding the benefits of family-centered care (FCC) in neonatal intensive care units. Key aspects related to neonatal FCC include the parents' presence in the ward and their participation in infants' daily care and decision-making processes. In addition, an environment that supports a private and comfortable space for each family member and infant, such as a single-family room, should be provided. To successfully implement FCC in neonatal intensive care units, the culture of care and hospital policies should be changed to successfully implement FCC in neonatal intensive care units, and appropriate training for medical staff is also required.

Parents' Views on Prolonged Maternal Hospital Stay With Sick Newborn Infants in a Tertiary Neonatal Unit in Sri Lanka

BACKGROUND

Mothers of infants in most Sri Lankan neonatal units are required to be "inpatients" during the entirety of their infant's stay. This traditional practice is closely aligned to the relatively newer model of family-integrated care.

PURPOSE

Exploration of parent's views regarding the expectation for mothers to remain in hospital for the entire duration of their infant's neonatal unit stay.

METHODS

Cross-sectional study of parents of infants admitted to the University neonatal unit of Colombo North Teaching Hospital, Ragama, Sri Lanka, using self-administered questionnaires in 2017.

RESULTS

We found that 40% (19/48) of mothers and 43% (16/37) of fathers preferred that mothers traveled from home, rather than being inpatients continuously, in order to care for older children, receive psychological support from family, and also due to other practical inconveniences of living in the hospital. The main barriers to women being able to travel from home were the need to safely provide expressed human milk for their hospitalized infants and current hospital administrative and societal attitudes.

IMPLICATIONS FOR PRACTICE AND RESEARCH

We found that a considerable number of parents with infants in the neonatal intensive care unit in Sri Lanka would like the option of the mother being able travel from home, rather than being confined to hospital. To facilitate this option, changes in hospital protocols and further research into storage and transportation of expressed mother's milk will be required. Improving facilities in hospital and providing more opportunities for families to interact with infants in neonatal intensive care unit will encourage mothers to remain in hospital continuously.

Effects of liberalising visiting policy and staff education on parental visiting duration in the neonatal unit

AIM

The effect of different neonatal unit access hour policies on parental visiting duration is unknown. Therefore, we analysed the effects of access hours policies and parental education on parental visiting duration.

METHOD

This prospective longitudinal cohort study was carried out in a level III neonatal unit from October 2020 to May 2022. Three cohorts were compared. The baseline cohort included 51 preterm infants with restricted visiting hours (October 2020 to May 2021). Cohort 1 comprised 35 preterm infants after liberalisation of visiting hours (June 2021 to November 2021). Cohort 2 consisted of 26 preterm infants after an educational program was implemented (December 2021 to May 2022). The primary outcome was the mean daily parental visiting duration.

RESULTS

Mean maternal visiting duration was 172 (standard deviation, SD ± 49.2), 195 (SD ± 64.4.), and 258 (SD ± 71.1) minutes/day at baseline and in cohorts 1 and 2 (significant increase from baseline and cohort 1 to cohort 2, p < 0.001). Mean paternal visiting duration did not change significantly across the cohorts: 133 (SD ± 47.2), 135 (SD ± 83.5), and 165 (SD ± 71.3) minutes/day.

CONCLUSION

Liberalisation of access hours did not increase parental visiting duration. Parental and staff education significantly increased maternal but not paternal visiting duration.

Effects of family-centered care on bonding: A systematic review

Most critically ill neonates require constant monitoring, continuous care, and supervision. However, distance created by admission and prolonged stay in a neonatal intensive care unit (NICU) may contribute to a delay in parent-infant bonding. This review aimed to determine how family-centered care (FCC) in the NICU affects parental bonding with critically ill infants. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to perform a systematic search of the literature within the following four electronic databases: Cumulative Index of Nursing and Allied Health Literature (CINAHL), MEDLINE, Cochrane Library, and Web of Science. The search was conducted through July/August 2020. Research quality was evaluated using the Johns Hopkins Nursing Evidence-Based Practice Grading Scale. Out of 816 articles identified through literature search, 16 of the studies met our inclusion criteria. The majority of the studies (n = 14) found FCC interventions resulted in a significant increase in parental bonding. Results showed evidence practicing FCC in the NICU setting supports early parent-infant bonding. Nurses should consider implementing evidence-based FCC strategies into practice, such as allowing parents unrestricted access to their infants. More rigorous research with larger samples is recommended. More studies are also needed focusing on father-infant dyads and mother-father-infant triads.

Parental Experiences of Neonatal Care: A Nationwide Study on Determinants of Excellence

INTRODUCTION

Infant- and family-centered developmental care can reduce adverse outcomes in both infants and parents. Parents' experiences of the care and staff treatment remain to be evaluated.

METHODS

Parents of infants admitted to neonatal units in Sweden from July 2020 to May 2022 responded to a questionnaire with standardized questions about in-hospital care. Exposures were hospital, gestational age, length of hospital stay, unit level, and bed density. The proportions of parents rating aspects of neonatal care as excellent, defined as five on a Likert scale, and the determinants of excellence were described. The results were benchmarked with ratings in adult somatic care.

RESULTS

A total of 4,475/13,108 (34%) parents responded. The ratings of excellent care varied by question from 65% to 90%. The largest variation in excellence between neonatal units (range 43-80%) was found for "participation and involvement." The proportion of excellence was significantly lower among parents of extremely preterm infants. Confidence in the staff was lower in parents of extremely preterm infants than in parents of term infants (56% vs. 83%). Longer hospital stays affected the experience of neonatal care adversely, whereas level of care and bed density were overall unrelated to the parental experience. Parents in neonatal care rated the care as excellent to a higher extent than patients cared for in adult medicine.

CONCLUSION

A majority of parents rated neonatal care in Sweden as excellent. The less frequent ratings of excellence among parents of extremely preterm infants indicate that more could be done to optimize parental involvement and support.

Depressive symptoms in mothers of preterm infants before and during COVID-19 restrictions in neonatal intensive care units

AIM

Little is known about the specific restriction measures used in intensive care units (NICUs) during the COVID-19 pandemic and their impact on parental well-being. Hence, this study aimed to assess the association between restriction measures and mothers' post-partum depressive symptoms.

METHODS

This comparative cohort study included mothers who gave birth before 35 weeks of gestation in Estonia. The outcome measure was mothers' post-partum depressive symptoms at the time of infant discharge, evaluated using the Edinburgh Postnatal Depression Scale (EPDS). In addition to the pandemic itself, the number of restriction measures in the NICUs was analysed as a potential explanatory factor for depressive symptoms.

RESULTS

The study included 55 mothers before the pandemic in 2018-2019 and 54 mothers during the COVID-19 pandemic in 2021. No significant difference was found in the median EPDS scores between the cohorts: 7.0 [interquartile range (IQR): 4.0-12.0] and 8.0 (IQR: 5.0-12.8) respectively. The number of restriction measures was not associated with mothers' EPDS scores in either unadjusted or adjusted models.

CONCLUSION

The COVID-19 pandemic or the number of restriction measures used in Estonian NICUs did not associate with mothers' post = partum depressive symptoms.

Improving NICU staff decision-making with parents in medical rounds: a pilot study of reflective group dialogue intervention

Introduction

The communication skills of healthcare professionals play a crucial role in successful shared decision-making with parents in neonatal intensive care. Improving communication skills can be achieved through practice and reflection on personal experiences after authentic interaction events with parents. The process of reflection typically involves three phases: description, reflection, and critical reflection. In this study, our aim was to explore the acceptability of the Reflective Group Dialogue intervention and its effectiveness in supporting the reflective process.

Methods

This qualitative pilot study was conducted in the neonatal intensive care unit at Uppsala University Children's Hospital, Sweden. The sample consisted of nine medical rounds with seven families, five neonatologists, seven registered nurses, and five assistant nurses. Purposive sampling was used to collect the data. The intervention comprised four elements: (1) before the intervention, a recorded presentation on shared decision-making was given to the entire unit staff, (2) an observation of a normal medical round discussion with parents, (3) an interview with parents about their experience after the same round, and (4) a reflective discussion with the participating health care professionals after the round. The parent interviews and reflective discussions were audio-recorded and transcribed verbatim. They were analyzed using thematic analysis as a theoretical strategy.

Results

Both parents and staff widely accepted the intervention and found it beneficial. We identified four discussions that remained in the descriptive phase of the reflection process, four that reached the reflective phase, and one that reached the critical reflection phase. The descriptive discussions were characterized by using a single perspective to reflect, often based on personal opinions. The reflective discussions included analyzing interaction sequences from both staff and parent perspectives and were primarily based on actual observations of communication during medical rounds. The critical discussion led to a new awareness of current practices concerning parental involvement in decision-making. These discussions also utilized "what-if" thinking to evaluate potential new practices and their pros and cons.

Conclusions

The intervention seems promising as it was perceived as beneficial by the recipients and facilitated reflection in most cases. However, to enhance the feasibility of the intervention, some improvements are discussed.

Multidimensional assessment of infant, parent and staff outcomes during a family centered care enhancement project in a tertiary neonatal intensive care unit: study protocol of a longitudinal cohort study

BACKGROUND

The therapeutic advances and progress in the care for preterm infants have enabled the regular survival of very immature infants. However, the high burden of lifelong sequelae following premature delivery constitutes an ongoing challenge. Regardless of premature delivery, parental mental health and a healthy parent-child relationship were identified as essential prerogatives for normal infant development. Family centered care (FCC) supports preterm infants and their families by respecting the particular developmental, social and emotional needs in the Neonatal Intensive Care Unit. Due to the large variations in concepts and goals of different FCC initiatives, scientific data on the benefits of FCC for the infant and family outcome are sparse and its effects on the clinical team need to be elaborated.

METHODS

This prospective single centre longitudinal cohort study enrols preterm infants ≤ 32 + 0 weeks of gestation and/or birthweight ≤ 1500 g and their parents at the neonatal department of the Giessen University Hospital, Giessen, Germany. Following a baseline period, the rollout of additional FCC elements is executed following a stepwise 6-months approach that covers the NICU environment, staff training, parental education and psychosocial support for parents. Recruitment is scheduled over a 5.5. year period from October 2020 to March 2026. The primary outcome is corrected gestational age at discharge. Secondary infant outcomes include neonatal morbidities, growth, and psychomotor development up to 24 months. Parental outcome measures are directed towards parental skills and satisfaction, parent-infant-interaction and mental health. Staff issues are elaborated with particular focus on the item workplace satisfaction. Quality improvement steps are monitored using the Plan- Do- Study- Act cycle method and outcome measures cover the infant, the parents and the medical team. The parallel data collection enables to study the interrelation between these three important areas of research. Sample size calculation was based on the primary outcome.

DISCUSSION

It is scientifically impossible to allocate improvements in outcome measures to individual enhancement steps of FCC that constitutes a continuous change in NICU culture and attitudes covering diverse areas of change. Therefore, our trial is designed to allocate childhood, parental and staff outcome measures during the stepwise changes introduced by a FCC intervention program.

TRIAL REGISTRATION

Clinicaltrials.gov, trial registration number NCT05286983, date of registration 03/18/2022, retrospectively registered, http://clinicaltrials.gov .

Maternal mental health and engagement in developmental care activities with preterm infants in the NICU

OBJECTIVE

To examine associations between maternal mental health and involvement in developmental care in the NICU.

STUDY DESIGN

Mothers of infants born <32 weeks gestation (n = 135) were approached to complete mental health screening questionnaires at two weeks after admission. Mothers who completed screening (n = 55) were further classified as with (n = 19) and without (n = 36) elevated scores. Mothers' frequency, rate, and duration of developmental care activities were documented in the electronic health record.

RESULTS

35% of screened mothers scored above the cutoff for clinical concern on ≥1 measure. No significant differences between the 3 groups were identified for rates, frequency, or amount of all developmental care, kangaroo care, and swaddled holding.

CONCLUSION

Elevated scores on maternal mental health questionnaires did not relate to developmental care. Maternal developmental care engagement may not indicate mental health status. Universal screening for psychological distress is required to accurately detect symptoms in mothers of hospitalized preterm infants.

Improving Neonatal Intensive Care Unit Quality and Safety with Family-Centered Care

There is strong evidence that family-centered care (FCC) improves the health and safety of infants and families in neonatal settings. In this review, we highlight the importance of common, evidence-based quality improvement (QI) methodology applied to FCC and the imperative to engage in partnership with neonatal intensive care unit (NICU) families. To further optimize NICU care, families should be included as essential team members in all NICU QI activities, not only FCC QI activities. Recommendations are provided for building inclusive FCC QI teams, assessing FCC, creating culture change, supporting health-care practitioners and working with parent-led organizations.

The association between infant salivary cortisol and parental presence in the neonatal intensive care unit during and after COVID-19 visitation restrictions: A cross-sectional study

OBJECTIVES

Parent-infant interaction in the neonatal intensive care unit (NICU) promotes health and reduces infant stress. During the COVID-19 pandemic, however, NICUs restricted parent-infant interaction to reduce viral transmission. This study examined the potential relationship between pandemic visitation restrictions, parental presence and infant stress as measured by salivary cortisol.

METHODS

A two-NICU cross-sectional study of infants with gestational age (GA) 23-41 weeks, both during (n = 34) and after (n = 38) visitation restrictions. We analysed parental presence with and without visitation restrictions. The relationship between infant salivary cortisol and self-reported parental NICU presence in hours per day was analysed using Pearson's r. A linear regression analysis included potential confounders, including GA and proxies for infant morbidity. The unstandardised B coefficient described the expected change in log-transformed salivary cortisol per unit change in each predictor variable.

RESULTS

Included infants had a mean (standard deviation) GA of 31(5) weeks. Both maternal and paternal NICU presence was lower with versus without visitation restrictions (both p ≤0.05). Log-transformed infant salivary cortisol correlated negatively with hours of parental presence (r = -0.40, p = .01). In the linear regression, GA (B = -0.03, p = .02) and central venous lines (B = 0.23, p = .04) contributed to the variance in salivary cortisol in addition to parental presence (B = -0.04 p = .04).

CONCLUSION

COVID-19-related visitation restrictions reduced NICU parent-infant interaction and may have increased infant stress. Low GA and central venous lines were associated with higher salivary cortisol. The interaction between immaturity, morbidity and parental presence was not within the scope of this study and merits further investigation.

Parental Participation in Preterm Infant Feeding in the Neonatal Intensive Care Unit

PURPOSE

To identify factors associated with parental participation in the feeding care of hospitalized preterm infants and determine associations between parental participation in feeding and infant neurobehavioral outcomes.

STUDY DESIGN AND METHODS

Secondary analysis of data collected during a larger study of preterm infants. Parental participation in gavage and oral feeding was measured as a proportion of all feeding opportunities. Neurobehavioral outcomes were measured using a neurobehavioral assessment and feeding milestones. Other data were collected from the electronic health record.

RESULTS

Parental participation in feeding was low. There were associations between parental participation in gavage feeding and infant sex, insurance type, maternal race, infant gestational age at birth, and birthweight. There were associations between parental participation in oral feeding and infant sex, insurance type, maternal race, and study group. Greater parental participation in feeding was associated with earlier achievement of some feeding milestones.

CLINICAL IMPLICATIONS

Parental participation in feeding can decrease the time required for infants to achieve feeding milestones, possibly leading to decreased length of hospitalization. Nurses should encourage parents to participate in caregiving for their preterm infants. Interventions are needed to remove barriers to parental participation in caregiving.

Skin-to-skin SDF positioning: The key to intersubjective intimacy between mother and very preterm newborn-A pilot matched-pair case-control study

Background

Skin-to-skin contact (SSC) has been widely studied in NICU and several meta-analyses have looked at its benefits, for both the baby and the parent. However, very few studies have investigated SSC' benefits for communication, in particular in the very-preterm newborn immediately after birth.

Aims

To investigate the immediate benefits of Supported Diagonal Flexion (SDF) positioning during SSC on the quality of mother-very-preterm newborn communication and to examine the coordination of the timing of communicative behaviors, just a few days after birth.

Subjects and study design

Monocentric prospective matched-pair case-control study. Thirty-four mothers and their very preterm infants (27 to 31 + 6 weeks GA, mean age at birth: 30 weeks GA) were assigned to one of the two SSC positioning, either the Vertical Control positioning (n = 17) or the SDF Intervention positioning (n = 17). Mother and newborn were filmed during the first 5 min of their first SSC.

Outcome measures

Infants' states of consciousness according to the Assessment of Preterm Infants' Behavior scale (APIB). Onset and duration of newborns' and mothers' vocalizations and their temporal proximity within a 1-s time-window.

Results

In comparison with the Vertical group, very preterm newborns in the SDF Intervention Group spent less time in a drowsy state and more in deep sleep. At 3.5 days of life, newborns' vocal production in SSC did not differ significantly between the two groups. Mothers offered a denser vocal envelope in the SDF group than in the Vertical group and their vocalizations were on average significantly longer. Moreover, in a one-second time-frame, temporal proximity of mother-very preterm newborn behaviors was greater in the SDF Intervention Group.

Conclusion

Although conducted on a limited number of dyads, our study shows that SDF positioning fosters mother-very preterm newborn intimate encounter during the very first skin to skin contact after delivery. Our pioneer data sheds light on the way a mother and her very preterm vocally meet, and constitutes a pilot step in the exploration of innate intersubjectivity in the context of very preterm birth.

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.

An international study on implementation and facilitators and barriers for parent-infant closeness in neonatal units

Importance

Parent-infant closeness and active parent participation in neonatal care are important for parent and infant health.

Objective

To give an overview of current neonatal settings and gain an in-depth understanding of facilitators and barriers to parent-infant closeness, zero-separation, in 19 countries.

Methods

Neonatal intensive care unit (NICU) professionals, representing 45 NICUs from a range of geographic regions in Europe and Canada, were purposefully selected and interviewed June-December 2018. Thematic analysis was conducted to identify, analyze and report patterns (themes) for parent-infant closeness across the entire series of interviews.

Results

Parent-infant separation during infant and/or maternity care is very common (42/45 units, 93%), despite the implementation of family integrated care (FICare) practices, including parent participation in medical rounds (17/45, 38%), structured education sessions for parents (16/45, 36%) and structured training for healthcare professionals (22/45, 49%). NICU professionals encountered four main themes with facilitators and barriers for parent-infant closeness on and between the hospital, unit, staff, and family level: Culture (jointly held characteristics, values, thinking and behaviors about parental presence and participation in the unit), Collaboration (the act of working together between and within different levels), Capacities (resources and policies), and Coaching (education to acquire and transfer knowledge and skills).

Interpretation

Implementing parent-infant closeness in the NICU is still challenging for healthcare professionals. Further optimization in neonatal care towards zero-separation and parent-infant closeness can be achieved by enforcing the 'four Cs for Closeness': Culture, Collaboration, Capacities, and Coaching.

Parent-infant closeness after preterm birth and depressive symptoms: A longitudinal study

Background

Preterm birth increases the risk for postpartum depression in both mothers and fathers, calling for strategies to alleviate and prevent depressive symptoms in parents of preterm infants. The aim of this study was to assess the association between early parent-infant closeness and later depressive symptoms among parents of preterm infants. We hypothesized that longer duration of closeness associate with fewer depressive symptoms in both parents.

Methods

This prospective cohort study included 23 neonatal intensive care units (NICUs) from 15 countries in 2018 to 2020. Each unit recruited families with preterm infants aiming to 30 families. The total duration of parents’ presence in the NICU, and separately parent-infant skin-to-skin contact and holding, were measured using a Closeness Diary up to 14  days. The Edinburgh Postnatal Depression Scale (EPDS) was used at discharge and at 4  months corrected age of the infant.

Results

The study included 684 mothers and 574 fathers. The median presence was 469   min (Q1 258 and Q3 1,087) per 24   h for the mothers and 259   min (Q1 100 and Q3 540) for the fathers; mean EPDS scores were 9.2 (SD 5.0) and 6.3 (SD 4.4) at discharge and 6.6 (4.7) and 4.3 (4.2) at 4  months, respectively. Parents’ presence and depressive symptoms varied greatly between the units. Parents’ presence as the total measure, or skin-to-skin contact and holding separately, did not associate with depressive symptoms in either mothers or fathers at either time point (adjusted).

Conclusion

No association was found between the duration of parent-infant closeness in the neonatal unit and parents’ depressive symptoms. The beneficial effects of family-centered care on parents’ depression seem to be mediated by other elements than parent-infant physical closeness. More research is needed to identify the critical elements which are needed to alleviate parents’ depression after NICU stay.

Usefulness of the Parental Electronic Diary During Medical Rounds in a NICU

Parental involvement in the care of their baby in family rooms in neonatal intensive care units (NICUs) can be improved. This could be done with an electronic medical report completed by the parents, which is then linked to the patient record system. The parents selected for this study completed an electronic diary during their stay in the NICU, while the staff answered a questionnaire about their opinion on the usefulness of the parents' diary. The length of stay, length of time the baby spent in Kangaroo care, breastfeeding, time given to breastfeeding, feeling of tiredness, the capability of identifying the newborn's signals, and parents' opinion on the diary were variables in the study. The NICU staff's opinion about the usefulness of the diary in decision-making was sought using a questionnaire. Eleven mothers and three fathers completed the diary. The median time for staying in the ward was 20 hours/day. The median time in Kangaroo care was 3 hours/day. The majority of mothers were breastfeeding on average 5 times per day. The commonest length of time for breastfeeding was 1 to 2 hours/day. The parents felt somewhat tired during their stay. All parents recognized their child's signals mostly or all the time. Most parents were happy with the diary. The nursing staff's opinions on the usefulness of the diary too were uniformly positive, whereas the doctors' opinions varied from positive to critical in nature. In conclusion, the diaries provided us with new information about parents' perceptions in the NICU. The nurses found the diary useful whereas the doctors were more critical.

Disparities in Kangaroo Care for Premature Infants in the Neonatal Intensive Care Unit

OBJECTIVE

The aim of this study was to investigate whether preterm infants whose families have lower socioeconomic status (SES) or communicate with clinical staff in a language other than English experience differences in the rate, frequency, and duration of kangaroo care (KC) in the neonatal intensive care unit (NICU) compared with preterm infants of higher SES or primarily English-speaking families.

METHODS

Participants were infants born <32 weeks' gestational age (GA), N = 116. We defined SES by the infants' health insurance (private/higher vs public/lower) and language by the language mothers used to communicate with clinical staff (English vs Other language). SES or language groups were compared on (1) rate of KC infants experienced during hospitalization per visitation days, (2) frequency of KC per visitation days, and (3) duration of KC events per day.

RESULTS

Infants in the lower SES and Other language groups experienced KC in reduced amounts, lower frequencies, and shorter durations than infants in either the higher SES or English language groups. SES and language group differences remained significant after controlling for family visitation and GA at birth. After controlling for SES, language group differences in KC duration remained significant.

CONCLUSION

Our findings revealed disparities in the rate, frequency, and duration of KC experienced in the NICU as a function of both SES and language. Such disparities reduced infants' access to this developmental care practice shown to stabilize clinical status and promote neurodevelopment. We recommend that hospital nurseries implement policies that minimize these disparities.

Initiation and duration of skin-to-skin contact for extremely and very preterm infants: A register study

AIM

This study sought to describe how skin-to-skin contact between extremely and very preterm infants and their parents is practised in Swedish neonatal units.

METHODS

Data from the Swedish Neonatal Quality Register from 2020 to 2021 were extracted to analyse initiation time and daily duration of skin-to-skin contact in different gestational ages and regions.

RESULTS

Of the 1475 infants in the cohort, mean (range) gestational age was 28 weeks (22-31), and mean (range) birthweight was 1205 g (360-2810). For extremely preterm infants (<28 weeks), median (interquartile range) skin-to-skin contact initiation time was at 88 postnatal hours (48-156) and 5% had skin-to-skin contact on the first day. For very preterm infants (<32 weeks), the corresponding numbers were 14 h (4-36) and 34%. Median (interquartile range) daily skin-to-skin contact duration for the entire cohort during the first day, first three and seven days and the remaining hospital stay was 0 (0-0), 0.7 (0-2.7), 1.6 (0.4-3.6) and 4.4 (3.0-6.1) h, respectively.

CONCLUSION

A minority of extremely and very preterm infants were exposed to skin-to-skin contact on the first postnatal day. Daily duration during the first week of life amounted to less than two hours. Initiation time and daily duration varied among gestational ages.

Comparisons of Three Measures of Maternal Engagement Activities in the Neonatal Intensive Care Unit

BACKGROUND

Mothers' engagement with their hospitalized preterm infant(s) is recognized as an important aspect of treatment in neonatal intensive care units (NICUs). However, no gold standard exists for measuring maternal engagement, and the various methods used to measure mothers' time have documented limitations.

OBJECTIVES

This study sought to compare three measurement methods of maternal engagement (a five-item maternal cross-sectional survey, time use diaries, and electronic health records [EHRs]) to identify whether these methods capture consistent data and patterns in detected differences in measures of engagement.

METHODS

Maternal engagement was defined as time spent visiting the infant in the NICU (presence), holding (blanket holding in the mother's arms or by kangaroo care [KC]), and caregiving (e.g., bathing and changing diapers). The survey estimating daily maternal engagement was administered in two Level III NICUs and one Level IV NICU at study enrollment, at least 2 weeks after admission. Mothers then completed the daily time use diaries until infant discharge. Data were also collected from participants' EHRs, charted by nursing staff. Wilcoxon signed-rank tests were used for pairwise analysis of the three measures for maternal engagement activities.

RESULTS

A total of 146 participants had data across all three measurement types and were included in the analysis. In the Level III NICUs (n = 101), EHR data showed significantly more time spent with all engagement activities than the diary data. In the Level IV data, only differences in time holding were significant when comparing EHR data with survey data, with mothers reporting more time doing KC and less time blanket holding. Comparison of EHR data with diary data showed more time in all activities except KC.

DISCUSSION

In most cases, time spent in engagement activities measured in the EHR was higher than in the surveys or time use diaries. Accuracy of measurements could not be determined because of limitations in data collection, and there is no gold standard for comparison. Nevertheless, findings contribute to ongoing efforts to develop the most valuable and accurate strategies for measuring maternal engagement-a significant predictor of maternal and infant health.

Mother-Infant Dyadic Synchrony in the NICU Context

BACKGROUND

Dyadic synchrony is a co-constructed social process relating to the back and forth interactions between mothers and infants that are strongly associated with neurodevelopment, self-regulation, and attachment. In the neonatal intensive care unit (NICU), this process may become interrupted because of the physiological state of the infant, the emotional state of the mother, and the physical environment of the NICU.

PURPOSE

In applying Feldman's Biobehavioral Model of Synchrony, this empirical review deconstructs the process of dyadic synchrony in the NICU context and provides a conceptual approach to guide both research and clinical practice.

METHODS

First, we examine the theoretical and empirical literature to explicate the primary structural and biophysiological components of synchrony and relate these constructs to the extant research on premature infants. Next, we synthesize the maternal, infant, and contextual factors that facilitate or inhibit the ontogenesis of dyadic synchrony in the NICU. The final section highlights the state of the science in dyadic synchrony in the NICU including gaps and recommendations for future research.

FINDINGS

An empirical review synthesis presents a visual conceptual framework to illustrate multiple processes that depict maternal, infant, and contextual influences of mother-infant synchrony in the NICU.

IMPLICATIONS FOR PRACTICE/RESEARCH

Despite the challenges posed to mother-infant relationships in the NICU, high-quality mother-infant interactions are possible, dyadic synchrony can emerge, and premature infants can develop secure attachments. Clinicians and researchers can apply this conceptual framework of mother-infant dyadic synchrony in the NICU to promote evidence-based research and clinical practice.

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..

Alberta Family Integrated Care™ and Standard Care: A Qualitative Study of Mothers' Experiences of their Journeying to Home from the Neonatal Intensive Care Unit

Globally, one in ten infants is born preterm. Most preterm infants require care in a level II Neonatal Intensive Care Unit (NICU), which are highly technological critical care environments that can be overwhelming for parents. Alberta Family Integrated Care (AB-FICare™) is an approach to care that provides strategies to integrate parents into their infant’s care team. This sub-study is the first to compare mothers’ experiences in the context of AB-FICare™ and standard care. Semi-structured interviews with mothers from AB-FICare™ (n = 14) and standard care (n = 12) NICUs were analyzed using interpretive description informed by grounded theory methods. We identified a major theme of Journeying to Home with six categories: Recovering from Birth, Adapting to the NICU, Caring for Baby, Coping with Daily Disruption, Seeing Progress, and Supporting Parenting. Mothers in the AB-FICare™ group identified an enhancement to standard care related to building reciprocal trust with healthcare providers that accelerated Journeying to Home.

Parent-infant skin-to-skin contact reduces the electrical activity of the diaphragm and stabilizes respiratory function in preterm infants

BACKGROUND

The physiological benefit of parent-infant skin-to-skin contact (SSC) is uncertain for preterm infants with ventilatory support. We aimed to investigate whether SSC stabilizes the respiration compared to incubator care in mechanically ventilated preterm infants.

METHODS

The prospective observational study was performed in Turku University Hospital, Finland. Preterm infants were eligible if they were born before 36 weeks gestation and received respiratory support with either invasive or non-invasive neurally adjusted ventilatory assist (NAVA). SSC was applied as soon as possible after birth. Respiratory variables were collected from the ventilator log data, and SSC episodes were compared with matched control periods during incubator care.

RESULTS

A total of 167 episodes of SSC were recorded from 17 preterm infants: 138 episodes during invasive NAVA and 29 episodes during non-invasive NAVA. During invasive NAVA, peak electrical activity of the diaphragm (Edi), minimum Edi, respiratory rate, time on backup ventilation, peak inspiratory pressure, and mean airway pressure were significantly lower in SSC than in incubator care. During non-invasive NAVA, peak Edi, minimum Edi, time on backup ventilation, and peak inspiratory pressure were significantly lower in SSC than in incubator care.

CONCLUSIONS

SSC stabilized and improved the respiratory physiology in mechanically ventilated preterm infants.

IMPACT

Skin-to-skin contact reduced work of breathing compared to incubator care in mechanically ventilated preterm infants. Skin-to-skin contact reduced the need for backup ventilation during neurally adjusted ventilatory assist in preterm infants. Skin-to-skin contact among ventilated preterm infants was not only safe but also stabilized and improved their respiratory physiology.

Socio-demographic factors related to parent engagement in the NICU and the impact of the SENSE program

BACKGROUND

Early parent engagement in the neonatal intensive care unit (NICU) is important for both parent and infant mental health and for improving developmental outcomes. It remains unclear how different programs, such as the Supporting and Enhancing NICU Sensory Experiences (SENSE) program, may empower parents from various socio-demographic groups to engage in the NICU. An improved understanding could aid in individualizing interventions for those at the highest risk for health disparities.

AIMS

This exploratory study, which was part of a larger study, sought to explore 1) socio-demographic factors related to parent presence and engagement in the NICU and 2) if the SENSE program related to increased parent presence and engagement among different socio-demographic groups.

METHODS

Seventy parent-infant dyads (born ≤ 32 weeks gestation) were randomized to SENSE programming (parent education and age-appropriate, positive sensory interventions for parents to conduct with their infants every day of hospitalization) or standard care after admission to the NICU. The amount of parent presence and participation in sensory activities was tracked using bedside logs, nursing records, and research team documentation.

RESULTS

Being married (p = 0.048; p = 0.01), having private insurance (p < 0.001; p = 0.01), and having fewer children (p = 0.004; p = 0.03) related to more parent presence and engagement respectively. Parents who were Black had less presence and engagement in the NICU (p = 0.04; p = 0.02). Participation in the SENSE program was related to more parent presence and engagement among younger mothers (p = 0.002; p ≤0.001) and among parents living farther distances from the hospital (p < 0.001; p = 0.004).

CONCLUSION

Programming, such as the SENSE program, can improve parent engagement in the NICU among high-risk groups.

Do Single-Family Rooms Increase Parental Presence, Involvement, and Maternal Well-Being in Neonatal Intensive Care?

Objectives of this study were to determine whether single-family room (SFR) design enhances parental presence, involvement, and maternal well-being during neonatal intensive care hospitalization. An observational cohort including mothers of infants was randomly assigned to receive care in a tertiary-level open-bay (OB) (n = 35) or SFR (n = 36). Mothers were asked to complete daily diaries documenting parental presence, involvement in care, and questionnaires examining maternal well-being. Mother and father mean presence (standard deviation) was significantly higher in the SFR-17.4 (5.2) and 13.6 (6.8)-compared to OB-11.9 (6.3) and 4.6 (3.7) hours/day. Total time spent in care activities did not differ for mothers, except SFR mothers spent more time expressing breast milk (EBM). SFR fathers had greater involvement with care activities. There were no other significant differences. The SFR was associated with greater maternal presence, but not greater involvement in care activities except for EBM, nor improved maternal well-being. The SFR appears to have greater impact on fathers' involvement in care and comforting activities, although the amount of time involved remained quite low compared with mothers. Further studies examining ways to enhance parental involvement in the neonatal intensive care unit are warranted.

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.

Preterm Birth Is Associated With Depression From Childhood to Early Adulthood

OBJECTIVE

There have been inconsistent findings on the associations among prematurity, poor fetal growth, and depression. We examined the associations among gestational age, poor fetal growth, and depression in individuals aged 5 to 25 years.

METHOD

We identified 37,682 case subjects based on International Classification of Diseases, Ninth Revision code 2961 and International Classification of Diseases, Tenth Revision codes F32.0-F32.9 and F33.0-F33.9 from the Care Register for Health Care, and 148,795 matched controls from the Finnish Central Population Register. Conditional logistic regression examined the associations between gestational age by each gestational week, poor fetal growth, and depression. The associations were adjusted for parental age and psychopathology, paternal immigrant status, maternal substance abuse, depression, number of previous births, marital status, socio-economic status, smoking during pregnancy, and the infant's birthplace.

RESULTS

In the adjusted models, increased risk of depression was found in children born ≤25 weeks (adjusted odds ratio [aOR] 1.89, 95% CI 1.08-3.31), at 26 weeks (aOR 2.62, 95% CI 1.49-4.61), at 27 weeks (aOR 1.93, 95% CI 1.05-3.53), and ≥42 weeks (aOR 1.11, 95% CI 1.05-1.19). In girls, extremely preterm birth was associated with depression diagnosed at 5 to 12 years (aOR 2.70, 95% CI 1.83-3.98) and 13 to 18 years (aOR 2.97, 95% CI 1.84-4.78). In boys, postterm birth (≥42 weeks) was associated with depression diagnosed at 19 to 25 years (aOR 1.28, 95% CI 1.07-1.54). Poor fetal growth was associated with an increased risk of depression in full-term infants (aOR 1.06, 95% CI 1.03-1.10) and postterm infants (aOR 1.24, 95% CI 1.08-1.43).

CONCLUSION

Preterm birth before 28 weeks of gestation appeared to play a role in the development of childhood depression. Smaller effects were also seen in postterm births, especially in boys.

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..

The validity of the Language Environment Analysis system in two neonatal intensive care units

AIM

To evaluate the validity of the Language Environment Analysis (LENA) system's automatic measures in two neonatal intensive care units supporting parent-infant closeness, and in two Finno-Ugric languages: Finnish and Estonian.

METHODS

The sound environment of 70 very preterm infants was recorded for 16 h in the neonatal intensive care units with the LENA system roughly at the gestational age of 32 (+2) weeks. Of these, the recordings of 14 infants (20%, two 5-min samples with a high percentage of speech, totally 140 min) were analysed in detail and in two different ways. Parental closeness diaries were used to document the presence of the parents. Agreements between LENA system and human coder estimates were analysed.

RESULTS

Findings showed a high variation in agreements. The highest agreements were found in female and adult word counts (r = 0.91 and 0.95). The agreements for child vocalisation count, conversational turns and silence were modest or low (r = -0.03 to 0.64).

CONCLUSION

Our study provides novel information on the validity of the LENA system in the neonatal intensive care unit. Findings show that the LENA system provides valid information on adult words, but LENA estimates for child vocalisations were less valid at this early age.

Development and psychometric evaluation of the CO-PARTNER tool for collaboration and parent participation in neonatal care

BACKGROUND

Active parent participation in neonatal care and collaboration between parents and professionals during infant hospitalization in the neonatal intensive care unit (NICU) is beneficial for infants and their parents. A tool is needed to support parents and to study the effects and implementation of parent-partnered models of neonatal care.

METHODS

We developed and psychometrically evaluated a tool measuring active parent participation and collaboration in neonatal care within six domains: Daily Care, Medical Care, Acquiring Information, Parent Advocacy, Time Spent with Infant and Closeness and Comforting the Infant. Items were generated in focus group discussions and in-depth interviews with professionals and parents. The tool was completed at NICU-discharge by 306 parents (174 mothers and 132 fathers) of preterm infants. Subsequently, we studied structural validity with confirmatory factor analysis (CFA), construct validity, using the Average Variance Extracted and Heterotrait-Monotrait ratio of correlations, and hypothesis testing with correlations and univariate linear regression. For internal consistency we calculated composite reliability (CR). We performed multiple imputations by chained equations for missing data.

RESULTS

A 31 item tool for parent participation and collaboration in neonatal care was developed. CFA revealed high factor loadings of items within each domain. Internal consistency was 0.558 to 0.938. Convergent validity and discriminant validity were strong. Higher scores correlated with less parent depressive symptoms (r = -0.141, 95%CI -0.240; -0.029, p = 0.0141), less impaired parent-infant bonding (r = -0.196, 95%CI -0.302; -0.056, p<0.0001), higher parent self-efficacy (r = 0.228, 95%CI 0.117; 0.332, p<0.0001), and higher parent satisfaction (r = 0.197, 95%CI 0.090; 0.308, p = 0.001). Parents in a family integrated care model had higher scores than in standard care (beta 6.020, 95%CI 4.144; 7.895, p<0.0001) and mothers scored higher than fathers (beta 2.103,95%CI 0.084; 4.121, p = 0.041).

CONCLUSION

The CO-PARTNER tool explicitly measures parents' participation and collaboration with professionals in neonatal care incorporating their unique roles in care provision, leadership, and connection to their infant. The tool consists of 31 items within six domains with good face, content, construct and structural validity.

Breastfeeding satisfaction post hospital discharge and associated factors - a longitudinal cohort study of mothers of preterm infants

Background

Mothers’ satisfaction with breastfeeding is important for breastfeeding duration but rarely investigated in mothers of preterm infants. The aim of this study was to describe breastfeeding satisfaction and associated factors during the first year in mothers of preterm infants (gestational age < 37 weeks).

Methods

This longitudinal cohort study, based on secondary analysis data from a randomized controlled trial, included 493 mothers of 547 preterm infants. Data on breastfeeding duration and satisfaction, parental stress and attachment were collected at 8 weeks post discharge, and at 6 and 12 months after birth. Breastfeeding satisfaction was measured by the Maternal Breastfeeding Evaluation Scale. Descriptive statistics and linear mixed effect models were used when analyzing the data.

Results

During the first 12 months breastfeeding satisfaction increased in the mean summary scores and points in the dimensions “role attainment” and “lifestyle and maternal body image”. In the dimension “infant growth and satisfaction”, there was an increase in mean points from 6 to 12 months after birth, but not between 8 weeks after discharge and 12 months after birth. The findings also showed that partial and no breastfeeding, higher parental stress, and infant gestational age < 32 weeks were associated with decreased breastfeeding satisfaction. Older maternal age and greater maternal attachment were associated with increased maternal breastfeeding satisfaction. There were no associations between maternal breastfeeding satisfaction and maternal educational level, parity, multiple birth, or maternal birth country other than Sweden, during the first 12 months after birth.

Conclusions

Breastfeeding satisfaction was clearly associated with breastfeeding duration during the first year after birth. Breastfeeding satisfaction may be important to take into account when supporting breastfeeding and when designing interventions to support breastfeeding. Furthermore, these findings highlight the complexity of breastfeeding and emphasize the need for early and good support during neonatal care, so that mothers feel trust in themselves and their infant and in exclusive breastfeeding at discharge and in the first months thereafter.

Trial registration

The randomized controlled trial was registered NCT01806480 with www.clinicaltrials.gov on 2013-03-07.

Case Report: Intact Survival of a Marginally Viable Male Infant Born Weighing 268 Grams at 24 Weeks Gestation

We report the case of a preterm small for gestational age male infant born at 24 weeks of gestation with a birth weight of 268 g who was discharged from our hospital without the requirement for home oxygen therapy or tube feeding. He did not experience severe intraventricular hemorrhage, periventricular leukomalacia, hearing disability, or any other serious complications. At that time (February 2019), according to the University of Iowa's Tiniest Babies Registry, he was the tiniest male infant in the world to survive without any serious complications other than severe retinopathy of prematurity that required laser therapy. Although the survival rate of infants with extremely low birth weight is improving worldwide, a high mortality rate and incidence of severe complications remain common for infants weighing <300 g at birth, particularly in male infants. In recent years, there have been frequent discussions regarding the ethical and social issues involved in treating extremely preterm infants weighing <400 g. Despite the challenges, reports of such infants surviving are increasing. Neonatal medicine has already achieved great success in treating infants weighing 400 g or more at birth. However, lack of evidence and experience may make physicians reluctant to treat infants weighing less than this. The present case demonstrates that intact survival of a marginally viable male infant with a birth weight of <300 g is possible with minimal handling and family involvement beginning shortly after birth. Our detailed description of the clinical course of this case should provide invaluable information to physicians around the world who treat such infants. This report will aid in the progress of neonatal medicine and help to address many of the social and ethical issues surrounding their care.

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.

Changes of Infant- and Family-Centered Care Practices Administered to Extremely Preterm Infants During Implementation of the NIDCAP Program

Introduction: Many studies have evaluated the Neonatal Individualized Developmental Care and Assessment Program (NIDCAP), but few studies have assessed changes in infant- and family-centered developmental care (IFCDC) practices during its implementation. Objectives: The primary objective of this single center study was to investigate the impact of the implementation of the NIDCAP program on IFCDC practices used for management of extremely preterm infants (EPIs). The secondary objective was to determine during implementation the impact of this program on the short-term medical outcomes of all EPIs hospitalized at our center. Methods: All EPIs (<28 weeks gestational age) who were hospitalized at Strasbourg University Hospital from 2007 to 2014 were initially included. Outborn infants were excluded. The data of EPIs were compared for three time periods: 2007 to 2008 (pre-NIDCAP), 2010 to 2011, and 2013 to 2014 (during-NIDCAP implementation) using appropriate statistical tests. The clinical and caring procedures used during the first 14 days of life were analyzed, with a focus on components of individualized developmental care (NIDCAP observations), infant pain management (number of painful procedures, clinical pain assessment), skin-to-skin contact (SSC; frequency, day of initiation, and duration), and family access and involvement in the care of their children (duration of parental presence, parental participation in care). The short-term mortality and morbidity at discharge were evaluated. Results: We examined 228 EPIs who received care during the three time periods. Over time, painful procedures decreased, but pain evaluations, parental involvement in care, individualized observations, and SSC increased (all p < 0.01). In addition, the first SSC was performed earlier (p = 0.03) and lasted longer (p < 0.01). There were no differences in mortality and morbidity, but there were reductions in the duration of mechanical ventilation (p = 0.02) and the time from birth to first extubation (p = 0.02), and an increase of weight gain at discharge (p = 0.02). Conclusion: NIDCAP implementation was accompanied by progressive, measurable, and significant changes in IFCDC strategies. There were, concomitantly, moderate but statistically significant improvements in multiple important outcome measures of all hospitalized EPI.

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.

Early parenting intervention promotes 24-month psychomotor development in preterm children

AIM

Although parenting is key to promoting healthy development of at-risk preterm infants, parents have often restricted access to neonatal intensive care units (NICUs). This study aimed to assess the effect of an early parenting intervention on the psychomotor outcome in preterm children at 24 months of corrected age.

METHODS

Forty-two preterm children and their parents were consecutively recruited at a level III NICU in Northern Italy and randomly allocated to early intervention (two educational peer-group sessions and four individual infant observation sessions) or care as usual (no educational or infant observation sessions). During NICU stay, parents provided information on daily holding and skin-to-skin. Psychomotor development was measured at 24 months of corrected age using the Griffith Mental Development Scales.

RESULTS

There were no significant differences in socio-demographic and clinical variables between early intervention (n = 21; 13 females) and care as usual (n = 21; 12 females) groups. At 24 months of corrected age, children in the early intervention arm had greater scores for global psychomotor development as well as for Hearing-Speech and Personal-Social sub-scales, compared to those in the care as usual group.

CONCLUSION

The present NICU parenting intervention was found to be associated with better psychomotor outcomes in preterm children at 24-month age. The effects were especially evident for domains related to language and socio-emotional functioning. Results are promising and should be retested with more heterogeneous and representative preterm sample.

The Development of Data Collection Tools to Measure Parent-Infant Closeness and Family-Centered Care in NICUs

Background

Preterm and sick infants benefit from parent–infant closeness and family‐centered care (FCC) in neonatal intensive care units (NICUs). Prospective and feasible tools are needed to measure these care practices to facilitate their implementation.

Aims

To describe the development process of three prospective data collection tools that measure parent–infant closeness and the quality of FCC.

Methods

Data collection tools were developed in an iterative process consisting of three development cycles. Feedback was gathered from parents, staff, and researchers. The first stages of development focused on the content validity, appropriate scaling, and optimization of the response rate of these tools.

Results

The study included parents of 490 infants and the nurses working at bedside in 15 NICUs in six countries. The Parent‐Infant Closeness Diary was developed to measure the daily duration of parental presence, holding, and skin‐to‐skin contact. The optimal duration for daily diaries was 14 consecutive days to maintain a good response rate. Parents provided reliable documentation of parent–infant closeness. Digital FCC tools covering the nine aspects of FCC for parents and nurses were developed to measure the quality of FCC. Participants provided answers on a 7‐point Likert scale. Parents’ response rates remained >50% for approximately 1 month, and the nurses’ mean response rate was 55% (39%–87%) for the 3‐month study period.

Linking Evidence to Action

These new tools provide prospective daily information to aid the implementation of parent–infant closeness and the quality of FCC in NICU in different countries. They can be used to study and evaluate the implementation of these clinical practices NICUs in an international context.

Family Rooms in Neonatal Intensive Care Units and Neonatal Outcomes: An International Survey and Linked Cohort Study

OBJECTIVES

To evaluate the proportion of neonatal intensive care units with facilities supporting parental presence in their infants' rooms throughout the 24-hour day (ie, infant-parent rooms) in high-income countries and to analyze the association of this with outcomes of extremely preterm infants.

STUDY DESIGN

In this survey and linked cohort study, we analyzed unit design and facilities for parents in 10 neonatal networks of 11 countries. We compared the composite outcome of mortality or major morbidity, length of stay, and individual morbidities between neonates admitted to units with and without infant-parent rooms by linking survey responses to patient data from 2015 for neonates of less than 29 weeks of gestation.

RESULTS

Of 331 units, 13.3% (44/331) provided infant-parent rooms. Patient-level data were available for 4662 infants admitted to 159 units in 7 networks; 28% of the infants were cared for in units with infant-parent rooms. Neonates from units with infant-parent rooms had lower odds of mortality or major morbidity (aOR, 0.76; 95% CI, 0.64-0.89), including lower odds of sepsis and bronchopulmonary dysplasia, than those from units without infant-parent rooms. The adjusted mean length of stay was 3.4 days shorter (95%, CI -4.7 to -3.1) in the units with infant-parent rooms.

CONCLUSIONS

The majority of units in high-income countries lack facilities to support parents' presence in their infants' rooms 24 hours per day. The availability vs absence of infant-parent rooms was associated with lower odds of composite outcome of mortality or major morbidity and a shorter length of stay.

Study protocol: parents as pain management in Swedish neonatal care - SWEpap, a multi-center randomized controlled trial

BACKGROUND

During the first period of life, critically ill as well as healthy newborn infants experience recurrent painful procedures. Parents are a valuable but often overlooked resource in procedural pain management in newborns. Interventions to improve parents' knowledge and involvement in infants' pain management are essential to implement in the care of the newborn infant. Neonatal pain research has studied a range of non-pharmacological pain alleviating strategies during painful procedures, yet, regarding combined multisensorial parent-driven non-pharmacological pain management, research is still lacking.

METHODS/DESIGN

A multi-center randomized controlled trial (RCT) with three parallel groups with the allocation ratio 1:1:1 is planned. The RCT "Parents as pain management in Swedish neonatal care - SWEpap", will investigate the efficacy of combined pain management with skin-to-skin contact, breastfeeding and live parental lullaby singing compared with standard pain care initiated by health care professionals, during routine metabolic screening of newborn infants (PKU-test).

DISCUSSION

Parental involvement in neonatal pain management enables a range of comforting parental interventions such as skin-to-skin contact, breastfeeding, rocking and soothing vocalizations. To date, few studies have been published examining the efficacy of combined multisensorial parent-driven interventions. So far, research shows that the use of combined parent-driven pain management such as skin-to-skin contact and breastfeeding, is more effective in reducing behavioral responses to pain in infants, than using the pain-relieving interventions alone. Combined parental soothing behaviors that provide rhythmic (holding/rocking/vocalizing) or orogustatory/orotactile (feeding/pacifying) stimulation that keep the parent close to the infant, are more effective in a painful context. In the SWEpap study we also include parental live lullaby singing, which is an unexplored but promising biopsychosocial, multimodal and multisensory pain alleviating adjuvant, especially in combination with skin-to-skin contact and breastfeeding.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT04341194 ) 10 April 2020.