Facilitation of skin-to-skin care and parental involvement through the physical environment

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Authors

Moen A, Tandberg BS, Mader S, Ludes M, Sizun J, White R

Click on the image to read the standard in brief.

Target group

Infants and parents

User group

Healthcare professionals, neonatal units, hospitals, administrators, architects, health services, and payer organisations

Statement of standard

A physical environment that facilitates parent-infant closeness and skin-to-skin care is considered in NICU planning. Facilitation of skin-to-skin contact with parental and family involvement through the physical environment.

Rationale

The design of the neonatal unit is fundamental to facilitate parental presence and involvement in care and for skin-to-skin contact throughout the 24 hours. The standard specifies important aspects in the physical environment of the NICU that facilitate active parental participation and parent empowerment in daily care. (1,2) Infant- and family-centred developmental care, including skin-to-skin contact between infant and parent, is a caring mode for newborn infants that is superior to traditional care in incubators or open beds (see Infant- & family-centred developmental care). (3–5) There are ethnographic studies showing that letting parents establish a secluded area around the infants bed gives a feeling of privacy that may increase parental satisfaction and presence, so called safe corners. (6)

Planning for a NICU environment integrates scientific evidence and is also an issue of practical and smart technical and design solutions. One main source of information and input should be through visits to units that have gone through the process of redesigning their unit, and discussion with colleagues about strengths and weaknesses of their design.

In the planning process it should be acknowledged that there may be a conflict between patient and family preferences and the preferences of the staff, building, and technical department or administration. Such conflicts should be handled with great caution with respect to the patients’ rights and interests. Free-speaking competent advocates for the patients’ interests should be appointed early in the process, and their view should be considered to represent the infant’s needs and wishes.

Benefits

Short-term benefits

Long-term benefits

Components of the standard

Component

Grading of evidence

Indicator of meeting the standard

For parents and family

  1. Parents and family are informed by healthcare professionals about principles and purpose of the design to facilitate skin-to-skin care and are part of the planning process for NICU design.

B (High quality)

Guideline, parent feedback, patient information sheet1

For healthcare professionals

  1. Healthcare professionals are part of the design team.

B (High quality)

Guideline

For neonatal unit

  1. The design ensures that parents and infants are protected from unwanted sensory exposure (noise, light, smell). (23,24)

A (Moderate quality)
B (High quality)

Guideline

  1. Facilities are available to ease transfer from incubator to skin-to-skin care and the use of simultaneous monitoring and respiratory support technologies to allow uninterrupted skin-to skin care.

B (High quality)

Guideline

  1. Hospital beds, which result in longer periods of skin-to-skin care(15,23), and reclining chairs suitable for mothers that have recently given birth and that allow adjustments of position are available.

A (High quality)

Guideline

For hospital

  1. Physical space and architectural standards in the design facilitate close infant-parent contact throughout the 24 hours, integrating a primary user’s perspective and cover delivery room, transfer areas, and NICU. (1)

B (High quality)

Guideline

  1. Over-night accommodation facilities for parents preferable in or close to the unit with possibilities for having all meals in the hospital are provided. (25)

A (Moderate quality)
B (High quality)

Guideline

For health service

  1. A national guideline for the physical and architectural standards in the NICU including a primary user’s perspective allowing close infant-parent contact throughout the 24 hours and entire hospital stay is available. (1,24)

B (High quality)

Guideline

1The indicator ‘patient information sheet’ is an example for written, detailed information, in which digital solutions are included, such as web-based systems, apps, brochures, information leaflets, and booklets.

Where to go

Further development

Grading of evidence

For parents and family

N/A

For healthcare professionals

  • Provide technical facilities to start skin-to-skin care immediately at the delivery unit and during transfer to the NICU for stable infants.

A (High quality)

For neonatal unit

  • Provide single family rooms or adequately sized protected patient treatment areas allowing undisturbed skin-to-skin care.(11)

A (High quality)

  • Optimise monitoring equipment and use wireless monitoring.

B (Moderate quality)

  • Provide adequately sized hospital beds for parents with high quality electrically adjustable mattresses.

B (Moderate quality)

  • Provide separate bathrooms for parents.

B (Moderate quality)

  • Provide flexible mounting of pumps, CPAP, and ventilators to easily move the patient without disconnecting equipment.

B (Moderate quality)

  • Provide a suitable area for visiting siblings and a visiting policy allowing siblings into the ward.

B (Moderate quality)

For hospital

  • Ensure space for both parents caring for the infant to provide skin-to-skin contact throughout the 24 hours.

B (Moderate quality)

For health service

N/A

Getting started

Initial steps

For parents and family

  • Parents are involved from the earliest steps in the process of re-design/re-arrangement of the NICU in order to ensure that their needs are met.

For healthcare professionals

  • Provide parents with a place to sit down beside their infant allowing the infant to be in physical contact with their parents and to hear parents’ voice.

For neonatal unit

  • Develop strategies for implementing skin-to-skin contact, bearing in mind the specific outline of the unit.
  • Work systematically with healthcare professionals to ensure the re-design/re-arrangement captures critical aspects of the parent-infant relationship and of skin-to-skin care.
  • Prioritise parent-infant areas before other unit demands for space.
  • Provide over-night accommodation and eating facilities preferably in the unit, if not possible in the hospital or nearby.

For hospital

  • If space is limited take all measures to prioritise the physical environment to facilitate parent stay and prolonged skin-to-skin care.
  • Colours or pictures that could be considered to improve the relax process of the parents during the admission.

For health service

  • Develop and implement a national guideline for the physical and architectural standards in the NICU with a primary user’s perspective allowing close infant-parent contact throughout the 24 hours and entire hospital stay.

  1. 1. Roué JM, Kuhn P, Lopez Maestro M, Maastrup RA, Mitanchez D, Westrup B, et al. Eight principles for patient-centred and family-centred care for newborns in the neonatal intensive care unit. Arch Dis Child Fetal Neonatal Ed. 2017 Jul;102(4):F364–8.
  2. 2. van Veenendaal NR, van Kempen AAMW, Franck LS, O’Brien K, Limpens J, van der Lee JH, et al. Hospitalising preterm infants in single family rooms versus open bay units: A systematic review and meta-analysis of impact on parents. EClinicalMedicine. 2020 Jun 1;23:100388.
  3. 3. World Health Organisation. WHO recommendations for care of the preterm or low-birth-weight infant [Internet]. Geneva: World Health Organization; 2022 [cited 2024 Sep 26]. (WHO Guidelines Approved by the Guidelines Review Committee). Available from: http://www.ncbi.nlm.nih.gov/books/NBK586704/
  4. 4. WHO Immediate KMC Study Group. Immediate “Kangaroo Mother Care” and Survival of Infants with Low Birth Weight. N Engl J Med. 2021 May 27;384(21):2028–38.
  5. 5. Brimdyr K, Stevens J, Svensson K, Blair A, Turner-Maffei C, Grady J, et al. Skin-to-skin contact after birth: Developing a research and practice guideline. Acta Paediatr Oslo Nor 1992. 2023 Aug;112(8):1633–43.
  6. 6. Flacking R, Dykes F. Creating a positive place and space in NICUs. Pract Midwife. 2014 Aug;17(7):18–20.
  7. 7. Linnér A, Lode Kolz K, Klemming S, Bergman N, Lilliesköld S, Markhus Pike H, et al. Immediate skin-to-skin contact may have beneficial effects on the cardiorespiratory stabilisation in very preterm infants. Acta Paediatr Oslo Nor 1992. 2022 Aug;111(8):1507–14.
  8. 8. Bergman N. “The neuroscience of birth-and the case for Zero Separation.” Curationis 37.2 [Internet]. 2014 [cited 2024 Sep 25]. Available from: https://view.officeapps.live.com/op/view.aspx?src=https%3A%2F%2Fskin2skincontact.com%2Ffiles%2Fkcbib2017.docx&wdOrigin=BROWSELINK
  9. 9. Ludington-Hoe SM, Johnson MW, Morgan K, Lewis T, Gutman J, Wilson PD, et al. Neurophysiologic assessment of neonatal sleep organization: preliminary results of a randomized, controlled trial of skin contact with preterm infants. Pediatrics. 2006 May;117(5):e909-923.
  10. 10. Johnston C, Campbell-Yeo M, Disher T, Benoit B, Fernandes A, Streiner D, et al. Skin-to-skin care for procedural pain in neonates. Cochrane Database Syst Rev. 2017 Feb 16;2(2):CD008435.
  11. 11. Lyngstad LT, Tandberg BS, Storm H, Ekeberg BL, Moen A. Does skin-to-skin contact reduce stress during diaper change in preterm infants? Early Hum Dev. 2014 Apr;90(4):169–72.
  12. 12. Blomqvist YT, Rubertsson C, Kylberg E, Jöreskog K, Nyqvist KH. Kangaroo Mother Care helps fathers of preterm infants gain confidence in the paternal role. J Adv Nurs. 2012 Sep;68(9):1988–96.
  13. 13. Lilliesköld S, Zwedberg S, Linnér A, Jonas W. Parents’ Experiences of Immediate Skin-to-Skin Contact After the Birth of Their Very Preterm Neonates. J Obstet Gynecol Neonatal Nurs JOGNN. 2022 Jan;51(1):53–64.
  14. 14. Klemming S, Lilliesköld S, Westrup B. Mother-Newborn Couplet Care from theory to practice to ensure zero separation for all newborns. Acta Paediatr Oslo Nor 1992. 2021 Nov;110(11):2951–7.
  15. 15. Raiskila S, Axelin A, Toome L, Caballero S, Tandberg BS, Montirosso R, et al. Parents’ presence and parent-infant closeness in 11 neonatal intensive care units in six European countries vary between and within the countries. Acta Paediatr Oslo Nor 1992. 2017 Jun;106(6):878–88.
  16. 16. Lester BM, Hawes K, Abar B, Sullivan M, Miller R, Bigsby R, et al. Single-Family Room Care and Neurobehavioral and Medical Outcomes in Preterm Infants. PEDIATRICS. 2014 Oct 1;134(4):754–60.
  17. 17. Feldman R, Eidelman AI. Skin-to-skin contact (Kangaroo Care) accelerates autonomic and neurobehavioural maturation in preterm infants. Dev Med Child Neurol. 2003 Apr;45(4):274–81.
  18. 18. Lester BM, Salisbury AL, Hawes K, Dansereau LM, Bigsby R, Laptook A, et al. 18-Month Follow-Up of Infants Cared for in a Single-Family Room Neonatal Intensive Care Unit. J Pediatr. 2016 Oct;177:84–9.
  19. 19. Gupta N, Deierl A, Hills E, Banerjee J. Systematic review confirmed the benefits of early skin-to-skin contact but highlighted lack of studies on very and extremely preterm infants. Acta Paediatr Oslo Nor 1992. 2021 Aug;110(8):2310–5.
  20. 20. Caskey M, Stephens B, Tucker R, Vohr B. Adult Talk in the NICU With Preterm Infants and Developmental Outcomes. PEDIATRICS. 2014 Mar 1;133(3):e578–84.
  21. 21. Caskey M, Stephens B, Tucker R, Vohr B. Importance of Parent Talk on the Development of Preterm Infant Vocalizations. PEDIATRICS. 2011 Nov 1;128(5):910–6.
  22. 22. Rand K, Lahav A. Impact of the NICU environment on language deprivation in preterm infants. Acta Paediatr Oslo Nor 1992. 2014 Mar;103(3):243–8.
  23. 23. van Veenendaal NR, Heideman WH, Limpens J, van der Lee JH, van Goudoever JB, van Kempen AAMW, et al. Hospitalising preterm infants in single family rooms versus open bay units: a systematic review and meta-analysis. Lancet Child Adolesc Health. 2019 Mar;3(3):147–57.
  24. 24. Altimier L, Barton SA, Bender J, Browne J, Harris D, Jaeger CB, et al. Recommended standards for newborn ICU design. J Perinatol Off J Calif Perinat Assoc. 2023 Dec;43(Suppl 1):2–16.
  25. 25. Visscher MO, McKeown K, Nurre M, Strange R, Mahan T, Kinnett M, et al. Skin Care for the Extremely Low-Birthweight Infant. NeoReviews. 2023 Apr 1;24(4):e229–42.

Second edition, December 2024. Previous edition reviewed by Dr Salvador Piris and Assoc Prof Ylva Thernström Blomqvist.

Lifecycle

5 years/next revision: 2028

Recommended citation

GFCNI, Moen A, Tandberg BS et al., European Standards of Care for Newborn Health: Facilitation of skin-to-skin care and parental involvement through the physical environment. 2024.

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