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

Authors 

Moen A, Hallberg B, Bambang Oetomo S, Ewald U, Fröst P, Ferrari F, Sizun J, White R

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.

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. Family-centred 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 TEG Infant- & family-centred developmental care) 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. (1)

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

  • Increased physical stability of the newborn infant (2–6)
  • Reduced mortality and infection rate (7)
  • Improved self-regulation and sleep (8,9)
  • Decreased newborn infant stress and pain (9–11)
  • Improved parental confidence (12,13)
  • Early parent-infant interaction (14)
  • Reduced length of parent-infant separation (15,16)

Long-term benefits

  • Improved cognitive and neurodevelopmental outcome (17–19)
  • Improved and prolonged exclusive breastfeeding (8,13)
  • Improved speech development (20–22)

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 sheet
       
For healthcare professionals    
2. Healthcare professionals are part of the design team. B (High quality) Guideline
       
For neonatal unit    
3. The design ensures that parents and infants are protected from unwanted sensory exposure (noise, light, smell). (16,23–25) A (Moderate quality)
B (High quality)
Guideline
       
4. 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
       
5. Hospital beds, which result in longer periods of skin-to-skin care (26), 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    
6. 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. B (High quality) Guideline
       
7. Over-night accommodation facilities for parents in or close to the ward with possibilities for having all meals in the hospital are provided. (26,27) A (Moderate quality)
B (High quality)
Guideline
       
For health service    
8. 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. (28) B (High quality) Guideline
       

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 in the delivery unit and during transfer to the NICU for stable infants.
B (Moderate 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 easy 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 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 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.
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.
 

Sources

  1. Flacking R, Dykes F. Creating a positive place and space in NICUs. Pract Midwife. 2014 Aug;17(7):18–20.
  2. Begum EA, Bonno M, Ohtani N, Yamashita S, Tanaka S, Yamamoto H, et al. Cerebral oxygenation responses during kangaroo care in low birth weight infants. BMC Pediatr. 2008 Nov 7;8:51.
  3. Föhe K, Kropf S, Avenarius S. Skin-to-skin contact improves gas exchange in premature infants. J Perinatol Off J Calif Perinat Assoc. 2000 Aug;20(5):311–5.
  4. Bergman NJ, Linley LL, Fawcus SR. Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200- to 2199-gram newborns. Acta Paediatr Oslo Nor 1992. 2004 Jun;93(6):779–85.
  5. Bloch-Salisbury E, Zuzarte I, Indic P, Bednarek F, Paydarfar D. Kangaroo care: cardio-respiratory relationships between the infant and caregiver. Early Hum Dev. 2014 Dec;90(12):843–50.
  6. Mitchell AJ, Yates C, Williams K, Hall RW. Effects of daily kangaroo care on cardiorespiratory parameters in preterm infants. J Neonatal-Perinat Med. 2013;6(3):243–9.
  7. Boundy EO, Dastjerdi R, Spiegelman D, Fawzi WW, Missmer SA, Lieberman E, et al. Kangaroo Mother Care and Neonatal Outcomes: A Meta-analysis. Pediatrics. 2016 Jan;137(1).
  8. 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.
  9. Johnston C, Campbell-Yeo M, Fernandes A, Inglis D, Streiner D, Zee R. Skin-to-skin care for procedural pain in neonates. Cochrane Database Syst Rev. 2014 Jan 23;(1):CD008435.
  10. 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.
  11. 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.
  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. Wataker H, Meberg A, Nestaas E. Neonatal family care for 24 hours per day: effects on maternal confidence and breast-feeding. J Perinat Neonatal Nurs. 2012 Dec;26(4):336–42.
  14. Baylis R, Ewald U, Gradin M, Hedberg Nyqvist K, Rubertsson C, Thernström Blomqvist Y. First-time events between parents and preterm infants are affected by the designs and routines of neonatal intensive care units. Acta Paediatr Oslo Nor 1992. 2014 Oct;103(10):1045–52.
  15. Blomqvist YT, Frölund L, Rubertsson C, Nyqvist KH. Provision of Kangaroo Mother Care: supportive factors and barriers perceived by parents. Scand J Caring Sci. 2013 Jun;27(2):345–53.
  16. Heinemann A-B, Hellström-Westas L, Hedberg Nyqvist K. Factors affecting parents’ presence with their extremely preterm infants in a neonatal intensive care room. Acta Paediatr Oslo Nor 1992. 2013 Jul;102(7):695–702.
  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. 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. Vohr B, McGowan E, McKinley L, Tucker R, Keszler L, Alksninis B. Differential Effects of the Single-Family Room Neonatal Intensive Care Unit on 18- to 24-Month Bayley Scores of Preterm Infants. J Pediatr. 2017 Jun;185:42-48.e1.
  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. Caskey M, Stephens B, Tucker R, Vohr B. Importance of parent talk on the development of preterm infant vocalizations. Pediatrics. 2011 Nov;128(5):910–6.
  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. Kuhn P, Astruc D, Messer J, Marlier L. Exploring the olfactory environment of premature newborns: a French survey of health care and cleaning products used in neonatal units. Acta Paediatr Oslo Nor 1992. 2011 Mar;100(3):334–9.
  24. Kuhn P, Zores C, Langlet C, Escande B, Astruc D, Dufour A. Moderate acoustic changes can disrupt the sleep of very preterm infants in their incubators. Acta Paediatr Oslo Nor 1992. 2013 Oct;102(10):949–54.
  25. Kuhn P, Zores C, Pebayle T, Hoeft A, Langlet C, Escande B, et al. Infants born very preterm react to variations of the acoustic environment in their incubator from a minimum signal-to-noise ratio threshold of 5 to 10 dBA. Pediatr Res. 2012 Apr;71(4 Pt 1):386–92.
  26. 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.
  27. Flacking R, Thomson G, Ekenberg L, Löwegren L, Wallin L. Influence of NICU co-care facilities and skin-to-skin contact on maternal stress in mothers of preterm infants. Sex Reprod Healthc Off J Swed Assoc Midwives. 2013 Oct;4(3):107–12.
  28. White RD, Smith JA, Shepley MM, Committee to Establish Recommended Standards for Newborn ICU Design. Recommended standards for newborn ICU design, eighth edition. J Perinatol Off J Calif Perinat Assoc. 2013 Apr;33 Suppl 1:S2-16.

November 2018 / 1st edition / next revision: 2023

Recommended citation

EFCNI, Moen A, Hallberg B et al., European Standards of Care for Newborn Health: Facilitation of skin-to-skin care and parental involvement through the physical environment. 2018.

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