The importance of parent presence and involvement in the single‐family room and open‐bay <scp>NICU</scp>

It is remarkable how the perception of an optimal environment for preterm infants has evolved since Dr. Julius Hess opened the first premature unit at Sarah Morris Hospital in Chicago in 1914 1. With the introduction of the incubator and gavage feeding, Dr. Martin Couney first introduced care of the preterm to the public in an exhibit at the 1939 New York Words Fair where visitors paid a fee to view preterm infants in incubators. Wet nurses provided breast milk, and infants were separated from their mothers. In 1960, Dr. Louis Gluck established the first ‘modern’ intensive care unit for high-risk infants at Yale New Haven Hospital, which resulted in the rapid expansion of NICUs in the US and internationally 2. The early premature nurseries and NICUs had an open-bay design, and infants in bays of 12–20 infants were often separated from their mothers for an extended time. As awareness gradually shifted to the importance of developmental care 3, the design concept shifted to fewer infants in a care area. The option of parent rooming-in became available in a limited fashion in the 1980s, and recommendations of a single room design first appeared in the 1990s 4. The stark differences between the environments of the crowded open-bay NICU from 1986 to 2009 and the current 80 bed single-family room NICU at Women & Infants Hospital are clearly seen in Figures 1 and 2. With the spread of the single-family room nursery design, multiple studies reported a spectrum of benefits including increased rates of breastfeeding 5, decreased mortality, decreased rates of infection, apnoea, length of initial hospitalisation and readmissions 5-8, and improved developmental outcomes 9, 10. A meta-analysis published by van Veenendaal et al. 11 in 2019 reported significantly lower rates of sepsis and higher rates of exclusive breastfeeding at discharge but no differences in growth or length of stay. Lester et al. 8, 10 noted that mothers in a single-family room nursery were more involved in their infant's care, including skin-to-skin care compared to open-bay NICU mothers, and that improved infant growth and developmental outcomes were mediated by increased developmental support and maternal involvement. In a multicenter clinical trial 12 (Canada, Australia and New Zealand) of Family Integrated Care in the NICU for infants <34 weeks, infants in the intervention arm had higher daily weight gain and were more likely to be providing exclusive breast milk feeding at discharge. It should be noted that parents in the intervention arm had to commit to be present at least six hours per day, attend education sessions, and actively care for their infant. Obtaining family commitment to spend extended periods of time in the NICU has been challenging in the US and may contribute to conflicting findings including one study 13 which reported increased Bayley language delays in infants cared for in a single-family room NICU. Among the mothers in the single-family room NICU, there was a high percentage of mothers on Medicaid 13 and parent visiting ranged from a low of 1.8 hours per week to a high of 104 hours per week. The authors suggest that low language scores may be secondary to low sensory exposure in the single-family room NICU. In this issue, Tandberg et al. 14 investigated the growth of a cohort of infants with gestational ages 28 + 0 through 32 + 0 weeks cared for in a single-family room unit and open-bay unit in Norway. The objective was to evaluate the effects of maternal involvement including parent presence and skin-to-skin on growth in the two units which had a common feeding protocol. The goal was to give 80 mL/kg of donor breast milk during the first 24 hours and thereafter increase the volume by 20 mL/kg/day until 180 mL/kg/day. All infants above 1250 g received full enteral feeds from day one. Enteral feeds were donor breast milk or preterm formula if breast milk was not available. Breast milk fortifier was added until the infant weighed 2000 g. Nutritional intake was excellent in both groups throughout the study. A slightly elevated carbohydrate and protein intake in the open-bay unit in the first eight days was attributed to intake of formula because of a shortage of donor breast milk. At discharge, 77% of infants in the single-family room and 69% in the open-bay unit were exclusively breastfeeding. All growth parameters and slopes of growth curves were similar in the two groups at birth, PMA 34 weeks, discharge, term date and four months post-term. Parents in the single-family room nursery, however, spent significantly more time in the unit and provided more skin-to-skin care than parents in the open-bay unit. What proved truly amazing in this Norwegian cohort was the amount of sustained parent involvement that occurred during the hospitalisation, not only in the single-family room group but in the open-bay group. Mothers in the single-family room versus open-bay units were present for a mean of 21 versus seven hours per day and fathers were present for 16 versus five hours per day, respectively, p < .0001. Total hours of either parent present in the first week were 226 versus 64 hours for the single-family room versus open-bay unit. Parents in the single-family room together provided a total of six hours per day of skin-to-skin care until 34 weeks PMA compared to 4.4 hours per day for parents in the open-bay unit. Finally, parents in both the single-family room and open-bay units were noted to have a relatively high per cent of mothers with university education, 50 and 70%, respectively. In a recent US report, Pineda et al. 15 reported 32 versus 19 hours/week of visitation for the first two weeks in a single-family room and open-bay unit. If we compare parent visiting between the two studies, parents in the Norwegian cohort spent seven times more hours in the single-family room NICU compared to the US single-family room NICU during week one, and even the parents in the Norwegian open-bay unit spent twice as much time with their infants as parents in the US single-family room, 64 versus 32 hours per week, respectively. So are we comparing apples to oranges? In fact, the populations obviously differ in a number of respects with rates of receiving breast milk at discharge in the Pineda study at 26 and 30% in the single-family room and open-bay units, respectively. A second report by Pineda et al. 16 in which 61% of infants were cared for in a single-family room NICU assessed effects of family characteristics, visiting and skin-to-skin on outcomes. This report identified that mothers who visited more often were more likely Caucasian, married, older, employed, had few other children, more family support and were more likely to provide breast milk. More skin-to-skin was associated with improved neonatal neurobehaviour scores and higher motor outcomes by parent report at four to five years of age. Although the amount of time spent with infants in the NICU is quite different in the two studies, both the Tandberg 14 and Pineda 16 studies support beneficial effects of increased parent presence and involvement in the NICU, and a possible dose effect. Finally, to ensure a good outcome for an infant one must have a healthy, secure and happy mother/family unit. Outcomes of preterm infants are impacted by multiple maternal, infant, NICU, psychosocial, social and societal factors that are often not measured or reported in outcome studies. In the methods section, the authors describe the healthcare system in Norway which appears particularly well suited for supporting parent involvement in the NICU. All hospital care is financed through a public health insurance system that is free for all citizens irrespective of income. Parents also have extensive publicly financed social security benefits during pregnancy and after birth, and both parents are generally entitled job leave with full compensation. This healthcare system allowed parents in both arms of the study to spend a substantial amount of time with their infant in the NICU and may therefore account for the similar growth trajectories of the study groups. Although the majority of single-family room NICU design studies 17 studies report improved outcomes for mother and infant both in the US and internationally, there are numerous important social and environmental mediators which impact on parent presence in the NICU and parent involvement in quality developmental care, including the characteristics of the healthcare system. I believe this study tells us that although the design of the NICU is an important contributor to improved outcomes, it is the human element of parent involvement and societal factors that allow the parent to be in the NICU for extended periods that are the ingredients required for successful outcomes. The author has no conflict of interests.

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