Early Human Development 85 (2009) S37–S38

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Early Human Development

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Family centered neonatal care

Umberto de Vonderweid a,⁎, Marialisa Leonessa b

a Pediatric and Neonatal Unit, S. Croce Hospital, Moncalieri, Italyb Hospital Neonatology and NICU, S. Anna Hospital, Turin, Italy

⁎ Corresponding author. S.C. Pediatria e NeonatologiFerdinando 3 10024 Torino, Italy.

E-mail address: j.rampazzi@emec-roma.com (U. de V

0378-3782/$ – see front matter © 2009 Elsevier Irelanddoi:10.1016/j.earlhumdev.2009.08.009

a b s t r a c t

a r t i c l e i n f o

A survey on parental access, environmental and individualized neonatal care procedures, breast milk feedingand kangaroo mother care was performed in all Italian NICUs. Mothers are allowed unrestricted access in 29%NICUs: the main reasons for limiting parental access are structural and organizational limitations andinterference with the staff activities. Most NICUs report reducing lights and noises for improvingenvironmental care. Nesting in the incubator and regular change of postures are frequently reported, whileindividualized developmental care procedures are uncommon, as is breast milk feeding at discharge.Kangaroo mother care is performed in 67% of NICUs.

© 2009 Elsevier Ireland Ltd. All rights reserved.

There is growing evidence that a relationship based, familycentered and developmentally supportive approach to NeonatalIntensive Care is effective in reducing neonatal morbidity and im-proving neuro-behavioural development of preterm infants [1–5].

The main components of this approach are: opening of NeonatalIntensive Care Units (NICUs) to parents, involvement of parents in thecare of their baby, parents' psychological support, the NeonatalIndividualized Developmental Care Program (NIDCAP), breast milkfeeding (BMF) and kangaroo mother care (KMC).

The situation of Italian NICUs with respect to these componentsof neonatal care was explored in 2001 by the Working Group onNeonatal Developmental Care of the Italian Society of Neonatologywith a questionnaire that was completed and returned by 109 of the112 Units [6].

The pre-requisite of family centered neonatal care is— of course—having parents entering the Unit without time restrictions. Unfortu-nately, free access is permitted to mothers in 29.4% of Italian NICUsonly, and even less frequently to fathers (24% of NICUs). Parentalvisiting time is scheduled in all other Units: 43 NICUs report a dailyvisiting time of less than 7 h, and 33 a daily visiting time of 7 h ormore.

The own Unit's parental visiting time is considered “appropriate”by 70% of doctors and 66.9% of nurses, “too restricted” by 24.5% ofdoctors and 12.2% of nurses, and “too long” by 5.5% of doctors and20.9% of nurses.

Why parental access to the NICU is restricted? The question wasasked to the Head of the Units where parental access is restricted.Answers were: structural/organizational reasons (limited Unit's space,excessive crowding, shortage of nurse staff), interference (withmedical

a, Ospedale S. Croce, Piazza A.

onderweid).

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and nursing routines, with emergency interventions) and, lessfrequently, type of patients and risk of infections.

We analyzed the relationship between the daily visiting time (intime-restricted NICUs) and the following structural/organizationalvariables: space (sq. meters of the Unit's patients rooms), patients(mean # of newborns in the Unit), crowding (mean # of newborns/Unit's space) and nurses workload (mean # of newborns/mean # ofnurses). None of these variables were correlated with visiting time,which does not seem to be influenced by structural conditions.

Problems of parents–staff relationship are still frequent in ItalianNICUs, and the presence of parents is often felt by nurses and doctorsas an interference with their activities. Interference is especially felt asa problem in Units where the parents are least present, being theirscheduled visiting time shortest. In Units with less than 7 h/dayvisiting time interference is reported by 41% of doctors and 37.5% ofnurses, while in Units with no visiting restrictions interference isreported by 3.1% of doctors and by 9.7% of nurses. In our view, thisapparently paradoxical result confirms the conclusions drawn fromthe analysis of structural/organizational factors: limiting the access ofparents to the NICU and perceiving their presence as an interferencewith the staff's activities are both the consequences of an unsolvedrelational problem. Parents–staff relationships and communication inthe NICU may be difficult, sometimes really hard (especially for thenurses), but should never be a reason for separating mothers andfathers from their babies.

Another aspect of family centered neonatal care is environmentaland individualized developmental care, and from this respect thesituation in Italian NICUs seems more promising.

Environmental care is largely practiced in Italian NICUs. Theprocedures most frequently reported in the questionnaire are thoseconcerning light-related stress (diurnal/nocturnal light intensityvariations, use of incubator covers, individual lighting…). Noise-related stress is also a frequent concern, but in this case the answers

S38 U. de Vonderweid, M. Leonessa / Early Human Development 85 (2009) S37–S38

tend to be less precise than in the previous case (like “avoidingexcessive noise”). Answers to the question about crowding usuallyrefer to an excessive presence of parents and very rarely to an excessof health professionals simultaneously present.

Individualized developmental care procedures are less frequentlyreported than environmental ones, and the answers in the question-naire tend to be rather imprecise. The use of some device(s) aroundthe infant's body (the “nest”) is the most widespread containmentprocedure. Specific containment procedures like wrapping, holding,handling and individualized nesting are rarely reported. Postural care,in the large majority of cases, is understood as “changing the infant'sbody position (supine–lateral–prone) at regular intervals”, whiledevelopmentally oriented individualized postural care procedures arerarely mentioned.

Questions regarding the care of the infant's sleep/wake states andthe individualization of routine care procedures are quite frequentlyanswered “no” or “yes” without specification, so that the answercannot be interpreted. The most frequently reported procedure is toavoid — when possible — performing routine procedures when theinfant is sleeping.

Breast milk feeding (BMF) is another very important component offamily centered neonatal care. Unfortunately, the percentage ofnewborns receiving at least some own mother's milk (both at thebreast or from the bottle) on discharge from the NICU are low. Only 10Units report that 75% or more of their very low birth weight infantsreceive BMF on discharge, and two thirds of Units report a BMF ratebelow 50% for VLBW infants. In Units where the mother's access isfree, a high BMF rate is more frequent than in Units where visitingtime is restricted to less than 7 h per day.

The last section of the questionnaire included some questionsconcerning Kangaroo Mother Care (KMC).

KMC is performed in 67% of Italian NICUs: in 56% of them there areno pre-defined time schedules for KMC and mothers are reported tobe free to practice it at their wish when they are in the Unit. Actually,the median duration of KMC is only 1 h per day, seven days per week.

Units that allow KMC to be performed are not different from thosethat do not allow it in terms of structural/organizational variables orenvironmental/individualized care procedures, while a clear relation-ship exists between KMC and visiting time. NICUs where parentalaccess is free report a KMC rate of 78%, and NICUs where visiting timeis scheduled report a KMC rate of 62%. Breast milk feeding ondischarge is also related to KMC: a high BMF rate is reported by 26.8%of NICUs where KMC is performed and 14.2% of NICUs where KMC isnot performed.

In conclusion, the overall picture of Italian NICUs with respect tofamily centered neonatal care is quite unsatisfactory. The relationshipbetween the parents and the staff is still a problem, and certainlymany nurses and doctors are far from viewing the parent as “theprimary caregiver and… member of the health care team” [7].

References

[1] SymingtonA,Pinelli J.Developmental care forpromotingdevelopment andpreventingmorbidity in preterm infants. http://www.nichd.nih.gov/ cochrane/cochrane.htm.

[2] Als H, Lawhon G, Brown E, Gibes R, Duffy FH, Mc Anulty GB, et al. Individualizedbehavioural and environmental care for the very low birth weight preterm infant atrisk for bronchopulmonary dysplasia: neonatal intensive care unit and develop-mental outcome. Pediatrics 1986;78:1123–32.

[3] Buehler D, Als H, Duffy F, McAnulty G, Liederman J. Effectiveness of individualizeddevelopmental care for low risk preterm infants: behavioral and electrophysiologicevidence. Pediatrics 1995;96:923–32.

[4] AlsH,Gilkerson L. The role of relationshipbaseddevelopmentally supportive newbornintensive care in strengthening outcome of preterm infants. Semin Perinatol 1997;21:178–89.

[5] Westrup B. Newborn Individualized Developmental Care and Assessment Program(NIDCAP)— family centereddevelopmentally supportive care. EarlyHumDev2007;83:443–9.

[6] de Vonderweid U, Forleo V, Petrina D, Sanesi C, Fertz C, Leonessa ML, et al. Neonataldevelopmental care in Italian Neonatal Intensive Care Units. Ital J Pediatr 2003;29:199–205.

[7] Vanderberg KA. Individualized developmental care for high risk newborns in theNICU: a practice guideline. Early Hum Dev 2007;83:433–42.