Early Human Development 90 (2014) 863–867
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Early Human Development journal homepage: www.elsevier.com/locate/earlhumdev
Trends in care practices reflecting parental involvement in neonatal care Simo Raiskila a,⁎, Anna Axelin b, Saara Rapeli a, Ina Vasko a, Liisa Lehtonen c a b c
University of Turku, Finland Department of Nursing Science, University of Turku, Finland Department of Pediatrics, Turku University Hospital, University of Turku, Finland
a r t i c l e
i n f o
Article history: Received 29 March 2014 Received in revised form 13 August 2014 Accepted 19 August 2014 Available online xxxx Keywords: Breastfeeding Skin-to-skin care Family centered care Growth
a b s t r a c t Background: Everyday care practices can facilitate or hinder parents' participation and involvement in neonatal care. Aims: To evaluate trends in family-centered care practices in the Neonatal Intensive Care unit in Turku University Hospital. Study design and subjects: In this retrospective study, the patient charts of very preterm infants were reviewed in 4 cohorts: 2001 to 2002 (n = 72), 2006 to 2007 (n = 69), 2009 to 2010 (n = 76), and 2011 to 2012 (n = 78). Outcome measures: Care practices with parental involvement were evaluated: 1) thermoregulation; 2) nutrition and feeding; 3) the beginning and number of skin-to-skin care episodes. As safety measures, the length of stay and weight gain were recorded at discharge. Results: The significant trends included: a decrease in gestational age at the end of incubator care (mean 33.4 [standard deviation (SD) 1.36] to 31.6 [SD 1.1], p b 0.001) and at the beginning of breast-feeding (35.3 [SD 1.34] to 33.1 [SD 1.89], p b 0.001), bottle feeding (from 34.1 [SD 1.04] to 33.3 [SD 1.51], p = 0.003) and skin-to-skin care (from 32.8 [SD 1.99] to 29.9 [SD 2.34], p b 0.001). The changes were most remarkable in the infants below 28 weeks. In addition, weight gain increased from 110 g to 159 g per week (p b 0.001). Conclusions: The hospital care practices of very preterm infants developed during the study period support parental involvement. During the same time period, the weight gain of very preterm infants improved, significantly. These practices can serve as indicators of progressive trends in family centered care. © 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction During the last decades, neonatal care has become more family centered so that the focus has broadened from disease-centered care to embrace the infant in the context of his/her family and community [1]. Today, family-centered care (FCC) is regarded as the standard neonatal care. Intensive care exposes very low birth weight (VLBW) infants and their parents to stressful situations and environment. Intensive care usually separates the infant from their parents [2]. Thus, FCC practices are aimed to reduce the stress caused by the intensive care environment and the psychosocial needs of the infants and their families. The FCC involves parents in infant care and in care-related decision-making and supports collaborative care between parents and staff. Parents are central in providing optimal emotional, social, and physical environment for the child development during hospital care and later at home. The FCC has several favorable effects on both infants and their parents [1,2]. The FCC decreases parents' anxiety and depression, increases parenting competency, and supports the development of early
⁎ Corresponding author. Tel.: +358 407384195. E-mail address: smrais@utu.fi (S. Raiskila).
http://dx.doi.org/10.1016/j.earlhumdev.2014.08.010 0378-3782/© 2014 Elsevier Ireland Ltd. All rights reserved.
interaction [1,3]. Parent–infant closeness and parent support have positive effects on the neurobehavioral development of the infant [4–6]. The FCC may be a cost savings instrument to health care systems by shortening hospitalization in preterm infants [7,8]. Our objective was to follow the development of care practices supporting and enabling parent closeness and participation in infant care in a neonatal unit. Care practices were divided into: 1) thermoregulation management, including duration of incubator care and warmer bed care; 2) enteral and oral feeding practices and with a focus on breast-feeding; and 3) parent–infant skin-to-skin care practices. 2. Patients and methods The study population consisted of very preterm infants who were born at less than 32 gestational weeks or birth weight less than 1500 g in Turku University Hospital. The study cohorts included infants born during the years: 2001–2002 (n = 72), 2006–2007 (n = 69), 2009–2010 (n = 76), and 2011–2012 (n = 78). Infants who died or were transferred to other hospitals were excluded. Patients with incomplete or unavailable documentation were excluded: 2001–2002 (n = 5), 2006–2007 (n = 1), 2009–2010 (n = 5), and 2011–2012 (n = 11). Altogether, 295 patient charts were reviewed.
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Table 1 Characteristics of the preterm infants in 2001–02, 2006–07, 2009–10, and 2011–12. Background variables
Years 2001–2002 (n = 72)
Years 2006–2007 (n = 69)
Years 2009–2010 (n = 76)
Years 2011–2012 (n = 78)
p-Value
Birth weight (g), mean (SD) Male (%) GA (weeks), mean (SD) b28 weeks (n) 28–31 weeks (n) ≥32 weeks (n)
1183 (333) 31 (43%) 29.4 (2.4) 18 46 8
1349 (369) 41 (59%) 29.7 (2.1) 14 52 3
1292 (383) 53 (79%) 29.8 (2.5) 18 48 10
1176 (362) 43 (55%) 29.0 (2.4) 26 46 6
0.01 0.012 0.175
The study unit is a level III NICU [9] with 18 beds in seven rooms accommodating two to four patients per room. The hospital has an average of 4000 deliveries per year and the catchment area has 7000 deliveries. An average of 600 of them are admitted in the NICU and 50 to 60 of them were VLBW infants. The staff included 45 nurses and 4 neonatologists (situation in 2011). During the study years, parents were entitled to paid parental leaves consisting of maternity leave for 105 weekdays, paternity leave of 18 weekdays, and parental leave (mother or father) of 158 weekdays adding up to 47 weeks. The FCC care is valued in the unit. In 1986, the SSC care in preterm infants was started. From year 2008, there has been one room for predischarge overnight stays available for families. The unit developed its FCC by a structured training program for the staff (the Close Collaboration with Parents Training Program [10]) from 2009 to 2012 aiming to improve parents' presence and participation in the infant care. Medical treatments developed in the unit according to the accumulating evidence regarding all aspects of neonatal care. Patient data were retrospectively reviewed from infants' hospital charts. Background data included gestational age (GA) at birth, birth weight, and gender. The parameters were categorized into: 1) thermoregulation i.e. the GA at the end of incubator and warmer bed care; 2) nutrition and feeding, including the proportion of infants getting enteral and parenteral nutrition on the first day of life, the GA at full enteral nutrition (i.e., the last day of intravenous fluids), and the GA at the beginning of bottle and breast-feeding and at full oral feedings (i.e., the last day of nasogastric tube); and 3) parent–infant closeness including the postnatal and gestational age at the beginning of SSC, and the number of SSC episodes during the first four weeks of life. In the unit the criteria allowing SSC included sufficient medical stability and the willingness of the parents to initiate SSC. The safety measures included weight gain from birth to discharge, GA at discharge, and length of hospital stay. The quality of the hand-written documentation varied. All documents were carefully reviewed as similar information could have been written or entered in different places in the documentation sheets or electronic charting system. Because of filing system, a part of patient charts were microfilmed or scanned which further complicated the data collection. The lowest quality was during the years 2001 to 2002. To assess the proportion of data entry errors and interpretation errors the data for five randomly selected subjects was re-entered by another person. The overall accuracy between the two entries was 71%.
Univariate comparisons between the birth cohorts were made with one way analysis of variance (ANOVA) for continuous variables, and chi-square tests for categorical variables. The associations between the outcome variables and the two birth cohorts were further studied using analysis of covariance controlling for gender and birth weight. In addition, gestational age, subgroup analyses were performed when the difference between the cohorts was significant. Statistical analyses were done using SPSS v. 20.0 (IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.). p-Values below 0.05 were considered as statistically significant. The study protocol was approved by the Ethical Committee of the Hospital District of Southwest Finland (16/180/2011). 3. Results 3.1. Patient characteristics The four study cohorts of preterm infants differed from each other in gender and birth weight but not in GA. Gender and birth weight were adjusted in the analyses. We found no time trends in the background factors (Table 1). 3.2. Thermoregulation The GA at the end of incubator care decreased during the study period (mean 33.4 (SD 1.36)) in the first cohort vs. 31.6 (SD 1.60) in the last cohort, p b 0.05. The GA at the end of warmer bed care decreased from 35.5 (SD 2.30) to 34.0 (SD 1.93), respectively, p b 0.001. (Table 2). 3.3. Nutrition Both parenteral and enteral feeding became significantly more intensive during the first 24 h of life. The infants reached full enteral feeding earlier in the later cohorts compared to the first cohort, but the age at when full oral feedings were reached did not change. Breastfeeding began approximately three weeks earlier while bottle-feeding less than a week earlier in the last cohort compared to the first cohort (Table 3). The proportion of infants beginning oral feeding on breast increased significantly during the study period. Eleven percent of infants began oral feeding on breast in the first cohort compared to 23% in the last
Table 2 Thermoregulation indicated by the gestational age in weeks at the end of incubator and warmer bed care presented as mean (SD). n Age at the end of incubator care b28 weeks 28–31 weeks ≥32 weeks Age at the end of warmer bed care b28 weeks 28–31 weeks ≥32 weeks
76 184 20 76 165 23
Years 2001–2002 (n = 72)
Years 2006–2007 (n = 69)
Years 2009–2010 (n = 76)
Years 2011–2012 (n = 78)
p-Value
33.4 (1.36)⁎ 33.3 (1.69)⁎ 33.2 (1.04)⁎ 35.1 (1.08) 35.5 (2.30) 36.4 (3.12) 34.9 (1.65) 36.3 (1.20)
32.3 (1.16) 31.9 (1.49) 32.5 (1.01) 34.3 (0.21) 34.2 (1.64) 34.6 (1.78) 34.0 (1.50) 36.6 (1.06)
32.1 (1.60)⁎ 31.5 (1.40) 32.0 (1.28) 34.7 (1.59) 34.3 (2.20) 34.7 (2.77) 33.7 (1.80) 36.1 (1.50)
31.6 (1.10) 31.1 (0.99) 31.8 (1.06) 32.4 (0.10) 34.0 (1.93) 34.3 (2.83) 33.5 (1.16) 34.4 (0.60)
b0.001 b0.001 b0.001 0.206 b0.001 0.106 0.001 0.062
⁎ Indicates a significant difference (p b 0.05) between this and the following cohort.
S. Raiskila et al. / Early Human Development 90 (2014) 863–867
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Table 3 Gestational age (in weeks) of the milestones of nutrition and feeding. Means (SD) are presented unless otherwise indicated. n Parenteral nutrition given from the first day of life (n, %) Enteral feeding during the first day of life (n, %) Full enteral nutrition b28 weeks 28–31 weeks ≥32 weeks Start of bottle feeding b28 weeks 28–31 weeks ≥32 weeks Start of breast feeding b28 weeks 28–31 weeks ≥32 weeks Full oral feeding
76 186 24 76 192 27 50 155 23
Years 2001–2002 (n = 72)
Years 2006–2007 (n = 69)
Years 2009–2010 (n = 76)
Years 2011–2012 (n = 78)
p-Value
12 (17.9%)⁎ 8 (11.1%)⁎ 32.5 (1.78)⁎ 32.0 (1.89)⁎ 32.4 (1.60) 34.6 (1.41) 34.1 (1.04) 34.4 (1.29) 33.7 (0.80) 34.9 (1.14) 35.3 (1.34) 36.2 (1.44) 34.8 (1.33) 35.2 (1.06) 36.4 (1.69)
56 (83.6%) 56 (81.2%) 31.6 (2.20) 29.8 (3.61) 31.9 (1.19) 31.3 (1.51) 33.7 (1.39) 34.4 (1.76) 33.5 (1.61) 35.4 (1.67) 34.4 (1.39) 35.7 (1.76) 34.3 (1.16) 34.0 (1.67) 36.1 (1.91)
61 (82.4%)⁎ 54 (71.1%)⁎ 31.1 (2.21) 28.4 (1.42) 31.4 (1.23) 34.3 (1.30) 33.9 (1.68)⁎
76 (97.4%) 75 (96.2%) 30.6 (2.16) 28.6 (2.21) 31.3 (1.00) 33.6 (0.51) 33.3 (1.51) 33.5 (1.91) 33.0 (1.33) 33.3 (0.44) 33.1 (1.89) 33.1 (2.70) 33.0 (1.49) 34.1 (0.66) 36.6 (2.83)
b0.001 b0.001 b0.001 b0.001 b0.001 0.608 0.003 0.339 0.023 0.071 b0.001 0.004 b0.001 0.063 0.367
34.4 (2.19) 33.5 (1.34) 35.2 (1.41) 34.7 (1.94)⁎ 35.5 (2.40)⁎ 34.1 (1.40)⁎ 36.5 (0.96) 36.7 (2.63)
⁎ Indicates a significant difference (p b 0.05) between this and the following cohort.
cohort. Especially, there was a remarkable change in the breastfeeding pattern in the infants born below 28 weeks of gestation. During the first three cohorts, only one infant, born below 28 weeks of gestation, began oral feeding from breast before bottle whereas most of the infants born below 28 weeks of gestation during the last cohort (57.1%) began breastfeeding before bottle-feeding (Table 3). 3.4. Skin-to-skin care The initiation of SSC was analyzed, both by GA and during postnatal age. In the whole study population, the SSC began three weeks (GA) earlier in the last cohort compared to the first cohort and 19 postnatal days earlier. (Table 4). The most prominent change was evident in the most immature infants: in the infants below 28 weeks, SSC began more than five weeks (GA) earlier in the last cohort compared to the first cohort, and 42 postnatal days earlier. The minimum GA at the initiation of SSC was 27.4 weeks during the first cohort compared to 24.6 weeks in the last cohort, and the minimum of postnatal age decreased from 12 to 1 day of age. (Table 4). The number of SSC episodes increased during the first four weeks of life from five episodes in the first cohort to 21 episodes in the last cohort. 3.5. Safety measures The weight gain from birth to discharge increased significantly during the study period from 110 g per week in 2001–2002 to 159 g per week during 2011–2012 (p b 0.001). There was no change in the length
of stay or in the gestational age at the discharge (Table 5). The main trends in the care practices are summarized in Fig. 1. 4. Discussion The hospital care practices of very preterm infants developed during the study period in all categories measured to the direction that supported parent–infant closeness and parental involvement. Especially, there was a significant change in SSC and breastfeeding. We could observe a sequence starting with intensified enteral nutrition leading to shorter use of iv-fluids and incubator care creating an easier access for skin-to-skin care which then created a natural place for early breastfeeding. The weight gain of very preterm infants improved significantly which could have been influenced by both increased skin-toskin care and changes in nutrition. Very early SSC is implemented and studied in the Nordic countries [11]. SSC is safe in infants at 22 to 27 of GA [12,13]. Increased skin-toskin care requires a better appreciation of parent–infant closeness in the care culture of the unit to motivate the staff to learn new skills in this care procedure related to infant transfer, temperature control, infant monitoring, and parent support. In addition there are many societal and cultural factors influencing SSC implementation. A recent report by Reynolds et al. [4] reported that infants below 30 gestational weeks were given SSC, on average, one day per week during the first four weeks after birth, which is comparable to our unit practice during 2001 to 2002. Gonya et al. [14] reported that 80% of preterm infants below 27 weeks were given SSC during the first week of their life comparable to our unit practice in 2011 to 2012. Systematic training
Table 4 The beginning of skin-to-skin care by gestational age in weeks and postnatal age in days, and the amount of SSC episodes during the first four weeks, presented as mean (SD) unless otherwise indicated. n
Age at the beginning of SSC b28 weeks 28–31 weeks ≥32 weeks SSC episodes per first four weeks Age at the beginning of SSC b28 weeks Median (q1, q3) [min, max] 28–31 weeks ≥32 weeks
Years 2001–2002 (n = 72)
Years 2006–2007 (n = 69)
Years 2009–2010 (n = 76)
Years 2011–2012 (n = 78)
p-Value
7.8 (7.2) 15.7 (10.3)⁎ 11.5 (6.8, 24,3) [5.0, 35.0]
29.9 (2.34) 27.2 (1.33) 30.7 (1.31) 33.6 (0.67) 20.9 (0.92) 5.1 (6.1) 7.1 (7.9) 4.0 (3.0, 7.3) [1.0, 31.0]
b0.001 b0.001 b0.001 0.160 b0.001 b0.001 b0.001 b0.001
176 23
42.5 (30.3, 64.5) [12.0, 83.0] 17.5 (11.8)⁎ 7.2 (5.4)⁎
31.0 (1.60) 29.4 (1.47) 31.5 (1.03) 36.0 10.6 (1.05)⁎ 11.4 (9.3) 21.4 (12.0) 20.0 (10.5, 31.8) [7.0, 43.0]
30.9 (2.02)⁎ 28.7 (1.44)⁎ 31.1 (1.15) 34.4 (1.06) 15.6 (0.91)⁎
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32.8 (1.99)⁎ 32.9 (2.84)⁎ 32.3 (1.57)⁎ 34.0 (0.84) 5.0 (0.91)⁎ 24.4 (19.9)⁎ 47.2 (20.3)⁎
8.0 (5.0) 25.0⁎
5.5 (3.4) 4.4 (1.6)
3.9 (4.8) 5.2 (4.5)
b0.001 0.001
74 176 23
⁎ Indicates a significant difference (p b 0.05) between this and the following cohort.
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S. Raiskila et al. / Early Human Development 90 (2014) 863–867
Table 5 The safety measures indicated by weight gain in grams per week, the length of hospital stay in days and the gestational age at the discharge in weeks presented as mean.
Weight gain (g/week) b28 weeks 28–31 weeks ≥32 weeks The length of hospital stay (days) b28 weeks 28–31 weeks ≥32 weeks GA at discharge b28 weeks 28–31 weeks ≥32 weeks
Years 2001–2002 (n = 72)
Years 2006–2007 (n = 69)
Years 2009–2010 (n = 76)
Years 2011–2012 (n = 78)
p-Value
110⁎ 109 110 116 55.4 91.7 46.6 35.0 37.6 39.4 36.8 38.3
136 131 135 133 57.8 90.0 46.2 33.4 37.4 38.9 36.8 37.6
147⁎ 140 148 129 58.8 95.5 50.2 30.5 38.1 40.1 37.4 38.1
159 155 162 139 58.2 90.7 49.1 27.4 37.6 39.2 37.0 36,6
b0.001 b0.001 b0.001 0.676 0.205 0.929 0.225 0.751 0.195 0.685 0.379 0.225
⁎ Indicates a significant difference (p b 0.05) between this and the following cohort.
program (The Close Collaboration with Parents Training Program) to improve FCC, seemed therefore, to be successful in both increasing the amount of SSC and its earlier initiation. More consistent care practices were also suggested by decreased variation from 11-day range in the first cohort to 6-day range in the last cohort in the initiation of SSC in the most immature infants.
YEAR WEEK
2001-2002
2006-2007
The increase in FCC and SSC, in addition to intensified nutrition, may be another factor to increase growth [15,16] and thereby shorten the need for incubator and warmer bed care. Earlier literature has shown that SSC supports breast-feeding [17,18], which was also seen in our study showing a development towards earlier initiation of breastfeeding. A larger proportion of infants began oral feeding on breast, which has
2009-2010
2011-2012
29 1st SSC
30 End of IV 1st SSC
1st SSC End of IV
31 End of IV
Out of INCUBATOR Out of INCUBATOR
Out of INCUBATOR 32
WARMER BED End of IV 1st SSC 1st BREAST/ BOTTLE feeding
Out of INCUBATOR 33 1st BOTTLE feeding 1st BOTTLE feeding 1st BOTTLE feeding 34
1st BREAST-feeding WARMER BED
WARMER BED 1st BREAST-feeding
1st BREAST-feeding 35
FULL ORAL FEEDING 36
FULL ORAL FEEDING WARMER BED FULL ORAL FEEDING
37
FULL ORAL FEEDING
HOME HOME
HOME HOME
Fig. 1. This figure summarizes the milestones (gestational age at the milestone on the vertical axis) in all study infants in relation to multiple measures presented in details in the tables. The trends towards earlier milestones can be seen by raising steps.
S. Raiskila et al. / Early Human Development 90 (2014) 863–867
been shown to be better compatible with breathing in preterm infants compared to bottle-feeding [19]. Our study showed that the incubator care duration became shorter. The increased growth in our study infants might be one factor making this shift possible because of improved innate thermoregulation. It has been shown to be safe (no effects on weight gain or body temperature) to move a preterm infant from an incubator to a warmer bed at the weight of 1300 to 1500 g [20]. The gestational age at the end of warmer bed care was also lower in the last cohort compared to the first one probably reflecting growth and thermoregulation even better than incubator time. On the other hand, the development towards shorter incubator care may indicate better appreciation of the parents' wish to communicate with their infant without the barrier of incubator wall. Incubator, even if not contraindicating SSC, is an obstacle and it can be easier to initiate SSC without needing to remove the infant from an incubator. In addition, the parents perceive less separation from their infant who is on a warmer bed as touching and speaking to their infant becomes more available without the physical barrier of the incubator wall. In the later cohorts, the duration of parenteral nutrition was shorter compared to the first cohort. IV-line has been reported as a barrier for SSC [21]. In addition, a shorter duration of parenteral nutrition can decrease infant pain, infections, and parental stress [22,23]. The shorter duration of parenteral nutrition was reached by beginning of both parenteral and enteral nutrition during the first day of life and by faster daily increase in the volumes of enteral nutrition. Shorter incubator care, increased SSC, and earlier breastfeeding were safe, without prolonging hospital time for the infants. Previous studies demonstrate that shorter hospitalizations associate with FCC interventions [8] or architectural changes in the unit [7]. In our study unit, the length of hospital stay did not shorten. Compared to the national [24] and international (Vermont Oxford Network) comparison populations, the study unit had shorter than average length of stay already at the beginning of the study. The study design was retrospective using historical cohorts, which limits the conclusions of causalities. One other limitation in this study was that the studied patient charts were mostly handwritten, microfilmed and scanned. The documentation of the care practices was not fully consistent. Therefore, a double check was made regarding the oldest charts, having the least optimal technical quality, to ensure the reliability of the interpretations of the documents. A limitation of the documentation was that it did not include the precise duration of SSC. The safety measures were, however, not affected by inaccuracies. The study sample was relatively large and it covered the whole unit's target population. The data were derived from documentation done “real time” as a part of daily routine, which can be considered more valid than the staff reports of perceived practices. As chart review did not burden the study subjects or the staff, it supports the feasibility of these measures to be used as FCC indicators. Current electronic patient charting systems could be modified to modernize these indicators. 5. Conclusions Significant changes were found in all care practices during the 11-year study period without endangering babies' growth or lengthening the hospital stay. These changes supported and enabled better parent involvement and infant growth. Our results show that less invasive neonatal care practices can be developed allowing more parent-infant closeness. Funding This study was supported by the Turku University Hospital Research Foundation, the South-West Finnish Fund of Neonatal Research, and the Turku University Hospital EVO Fund (13898).
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Conflict of interest statement The authors declare that there are no conflicts of interest.
Acknowledgments We acknowledge our statistician Jaakko Matomäki, M.Sc. and also Robert M. Badeau, Ph.D., Aura Professional English Consulting, Ltd., for the language content editing of this manuscript.
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Early Human Development journal homepage: www.elsevier.com/locate/earlhumdev
Trends in care practices reflecting parental involvement in neonatal care Simo Raiskila a,⁎, Anna Axelin b, Saara Rapeli a, Ina Vasko a, Liisa Lehtonen c a b c
University of Turku, Finland Department of Nursing Science, University of Turku, Finland Department of Pediatrics, Turku University Hospital, University of Turku, Finland
a r t i c l e
i n f o
Article history: Received 29 March 2014 Received in revised form 13 August 2014 Accepted 19 August 2014 Available online xxxx Keywords: Breastfeeding Skin-to-skin care Family centered care Growth
a b s t r a c t Background: Everyday care practices can facilitate or hinder parents' participation and involvement in neonatal care. Aims: To evaluate trends in family-centered care practices in the Neonatal Intensive Care unit in Turku University Hospital. Study design and subjects: In this retrospective study, the patient charts of very preterm infants were reviewed in 4 cohorts: 2001 to 2002 (n = 72), 2006 to 2007 (n = 69), 2009 to 2010 (n = 76), and 2011 to 2012 (n = 78). Outcome measures: Care practices with parental involvement were evaluated: 1) thermoregulation; 2) nutrition and feeding; 3) the beginning and number of skin-to-skin care episodes. As safety measures, the length of stay and weight gain were recorded at discharge. Results: The significant trends included: a decrease in gestational age at the end of incubator care (mean 33.4 [standard deviation (SD) 1.36] to 31.6 [SD 1.1], p b 0.001) and at the beginning of breast-feeding (35.3 [SD 1.34] to 33.1 [SD 1.89], p b 0.001), bottle feeding (from 34.1 [SD 1.04] to 33.3 [SD 1.51], p = 0.003) and skin-to-skin care (from 32.8 [SD 1.99] to 29.9 [SD 2.34], p b 0.001). The changes were most remarkable in the infants below 28 weeks. In addition, weight gain increased from 110 g to 159 g per week (p b 0.001). Conclusions: The hospital care practices of very preterm infants developed during the study period support parental involvement. During the same time period, the weight gain of very preterm infants improved, significantly. These practices can serve as indicators of progressive trends in family centered care. © 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction During the last decades, neonatal care has become more family centered so that the focus has broadened from disease-centered care to embrace the infant in the context of his/her family and community [1]. Today, family-centered care (FCC) is regarded as the standard neonatal care. Intensive care exposes very low birth weight (VLBW) infants and their parents to stressful situations and environment. Intensive care usually separates the infant from their parents [2]. Thus, FCC practices are aimed to reduce the stress caused by the intensive care environment and the psychosocial needs of the infants and their families. The FCC involves parents in infant care and in care-related decision-making and supports collaborative care between parents and staff. Parents are central in providing optimal emotional, social, and physical environment for the child development during hospital care and later at home. The FCC has several favorable effects on both infants and their parents [1,2]. The FCC decreases parents' anxiety and depression, increases parenting competency, and supports the development of early
⁎ Corresponding author. Tel.: +358 407384195. E-mail address: smrais@utu.fi (S. Raiskila).
http://dx.doi.org/10.1016/j.earlhumdev.2014.08.010 0378-3782/© 2014 Elsevier Ireland Ltd. All rights reserved.
interaction [1,3]. Parent–infant closeness and parent support have positive effects on the neurobehavioral development of the infant [4–6]. The FCC may be a cost savings instrument to health care systems by shortening hospitalization in preterm infants [7,8]. Our objective was to follow the development of care practices supporting and enabling parent closeness and participation in infant care in a neonatal unit. Care practices were divided into: 1) thermoregulation management, including duration of incubator care and warmer bed care; 2) enteral and oral feeding practices and with a focus on breast-feeding; and 3) parent–infant skin-to-skin care practices. 2. Patients and methods The study population consisted of very preterm infants who were born at less than 32 gestational weeks or birth weight less than 1500 g in Turku University Hospital. The study cohorts included infants born during the years: 2001–2002 (n = 72), 2006–2007 (n = 69), 2009–2010 (n = 76), and 2011–2012 (n = 78). Infants who died or were transferred to other hospitals were excluded. Patients with incomplete or unavailable documentation were excluded: 2001–2002 (n = 5), 2006–2007 (n = 1), 2009–2010 (n = 5), and 2011–2012 (n = 11). Altogether, 295 patient charts were reviewed.
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Table 1 Characteristics of the preterm infants in 2001–02, 2006–07, 2009–10, and 2011–12. Background variables
Years 2001–2002 (n = 72)
Years 2006–2007 (n = 69)
Years 2009–2010 (n = 76)
Years 2011–2012 (n = 78)
p-Value
Birth weight (g), mean (SD) Male (%) GA (weeks), mean (SD) b28 weeks (n) 28–31 weeks (n) ≥32 weeks (n)
1183 (333) 31 (43%) 29.4 (2.4) 18 46 8
1349 (369) 41 (59%) 29.7 (2.1) 14 52 3
1292 (383) 53 (79%) 29.8 (2.5) 18 48 10
1176 (362) 43 (55%) 29.0 (2.4) 26 46 6
0.01 0.012 0.175
The study unit is a level III NICU [9] with 18 beds in seven rooms accommodating two to four patients per room. The hospital has an average of 4000 deliveries per year and the catchment area has 7000 deliveries. An average of 600 of them are admitted in the NICU and 50 to 60 of them were VLBW infants. The staff included 45 nurses and 4 neonatologists (situation in 2011). During the study years, parents were entitled to paid parental leaves consisting of maternity leave for 105 weekdays, paternity leave of 18 weekdays, and parental leave (mother or father) of 158 weekdays adding up to 47 weeks. The FCC care is valued in the unit. In 1986, the SSC care in preterm infants was started. From year 2008, there has been one room for predischarge overnight stays available for families. The unit developed its FCC by a structured training program for the staff (the Close Collaboration with Parents Training Program [10]) from 2009 to 2012 aiming to improve parents' presence and participation in the infant care. Medical treatments developed in the unit according to the accumulating evidence regarding all aspects of neonatal care. Patient data were retrospectively reviewed from infants' hospital charts. Background data included gestational age (GA) at birth, birth weight, and gender. The parameters were categorized into: 1) thermoregulation i.e. the GA at the end of incubator and warmer bed care; 2) nutrition and feeding, including the proportion of infants getting enteral and parenteral nutrition on the first day of life, the GA at full enteral nutrition (i.e., the last day of intravenous fluids), and the GA at the beginning of bottle and breast-feeding and at full oral feedings (i.e., the last day of nasogastric tube); and 3) parent–infant closeness including the postnatal and gestational age at the beginning of SSC, and the number of SSC episodes during the first four weeks of life. In the unit the criteria allowing SSC included sufficient medical stability and the willingness of the parents to initiate SSC. The safety measures included weight gain from birth to discharge, GA at discharge, and length of hospital stay. The quality of the hand-written documentation varied. All documents were carefully reviewed as similar information could have been written or entered in different places in the documentation sheets or electronic charting system. Because of filing system, a part of patient charts were microfilmed or scanned which further complicated the data collection. The lowest quality was during the years 2001 to 2002. To assess the proportion of data entry errors and interpretation errors the data for five randomly selected subjects was re-entered by another person. The overall accuracy between the two entries was 71%.
Univariate comparisons between the birth cohorts were made with one way analysis of variance (ANOVA) for continuous variables, and chi-square tests for categorical variables. The associations between the outcome variables and the two birth cohorts were further studied using analysis of covariance controlling for gender and birth weight. In addition, gestational age, subgroup analyses were performed when the difference between the cohorts was significant. Statistical analyses were done using SPSS v. 20.0 (IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.). p-Values below 0.05 were considered as statistically significant. The study protocol was approved by the Ethical Committee of the Hospital District of Southwest Finland (16/180/2011). 3. Results 3.1. Patient characteristics The four study cohorts of preterm infants differed from each other in gender and birth weight but not in GA. Gender and birth weight were adjusted in the analyses. We found no time trends in the background factors (Table 1). 3.2. Thermoregulation The GA at the end of incubator care decreased during the study period (mean 33.4 (SD 1.36)) in the first cohort vs. 31.6 (SD 1.60) in the last cohort, p b 0.05. The GA at the end of warmer bed care decreased from 35.5 (SD 2.30) to 34.0 (SD 1.93), respectively, p b 0.001. (Table 2). 3.3. Nutrition Both parenteral and enteral feeding became significantly more intensive during the first 24 h of life. The infants reached full enteral feeding earlier in the later cohorts compared to the first cohort, but the age at when full oral feedings were reached did not change. Breastfeeding began approximately three weeks earlier while bottle-feeding less than a week earlier in the last cohort compared to the first cohort (Table 3). The proportion of infants beginning oral feeding on breast increased significantly during the study period. Eleven percent of infants began oral feeding on breast in the first cohort compared to 23% in the last
Table 2 Thermoregulation indicated by the gestational age in weeks at the end of incubator and warmer bed care presented as mean (SD). n Age at the end of incubator care b28 weeks 28–31 weeks ≥32 weeks Age at the end of warmer bed care b28 weeks 28–31 weeks ≥32 weeks
76 184 20 76 165 23
Years 2001–2002 (n = 72)
Years 2006–2007 (n = 69)
Years 2009–2010 (n = 76)
Years 2011–2012 (n = 78)
p-Value
33.4 (1.36)⁎ 33.3 (1.69)⁎ 33.2 (1.04)⁎ 35.1 (1.08) 35.5 (2.30) 36.4 (3.12) 34.9 (1.65) 36.3 (1.20)
32.3 (1.16) 31.9 (1.49) 32.5 (1.01) 34.3 (0.21) 34.2 (1.64) 34.6 (1.78) 34.0 (1.50) 36.6 (1.06)
32.1 (1.60)⁎ 31.5 (1.40) 32.0 (1.28) 34.7 (1.59) 34.3 (2.20) 34.7 (2.77) 33.7 (1.80) 36.1 (1.50)
31.6 (1.10) 31.1 (0.99) 31.8 (1.06) 32.4 (0.10) 34.0 (1.93) 34.3 (2.83) 33.5 (1.16) 34.4 (0.60)
b0.001 b0.001 b0.001 0.206 b0.001 0.106 0.001 0.062
⁎ Indicates a significant difference (p b 0.05) between this and the following cohort.
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Table 3 Gestational age (in weeks) of the milestones of nutrition and feeding. Means (SD) are presented unless otherwise indicated. n Parenteral nutrition given from the first day of life (n, %) Enteral feeding during the first day of life (n, %) Full enteral nutrition b28 weeks 28–31 weeks ≥32 weeks Start of bottle feeding b28 weeks 28–31 weeks ≥32 weeks Start of breast feeding b28 weeks 28–31 weeks ≥32 weeks Full oral feeding
76 186 24 76 192 27 50 155 23
Years 2001–2002 (n = 72)
Years 2006–2007 (n = 69)
Years 2009–2010 (n = 76)
Years 2011–2012 (n = 78)
p-Value
12 (17.9%)⁎ 8 (11.1%)⁎ 32.5 (1.78)⁎ 32.0 (1.89)⁎ 32.4 (1.60) 34.6 (1.41) 34.1 (1.04) 34.4 (1.29) 33.7 (0.80) 34.9 (1.14) 35.3 (1.34) 36.2 (1.44) 34.8 (1.33) 35.2 (1.06) 36.4 (1.69)
56 (83.6%) 56 (81.2%) 31.6 (2.20) 29.8 (3.61) 31.9 (1.19) 31.3 (1.51) 33.7 (1.39) 34.4 (1.76) 33.5 (1.61) 35.4 (1.67) 34.4 (1.39) 35.7 (1.76) 34.3 (1.16) 34.0 (1.67) 36.1 (1.91)
61 (82.4%)⁎ 54 (71.1%)⁎ 31.1 (2.21) 28.4 (1.42) 31.4 (1.23) 34.3 (1.30) 33.9 (1.68)⁎
76 (97.4%) 75 (96.2%) 30.6 (2.16) 28.6 (2.21) 31.3 (1.00) 33.6 (0.51) 33.3 (1.51) 33.5 (1.91) 33.0 (1.33) 33.3 (0.44) 33.1 (1.89) 33.1 (2.70) 33.0 (1.49) 34.1 (0.66) 36.6 (2.83)
b0.001 b0.001 b0.001 b0.001 b0.001 0.608 0.003 0.339 0.023 0.071 b0.001 0.004 b0.001 0.063 0.367
34.4 (2.19) 33.5 (1.34) 35.2 (1.41) 34.7 (1.94)⁎ 35.5 (2.40)⁎ 34.1 (1.40)⁎ 36.5 (0.96) 36.7 (2.63)
⁎ Indicates a significant difference (p b 0.05) between this and the following cohort.
cohort. Especially, there was a remarkable change in the breastfeeding pattern in the infants born below 28 weeks of gestation. During the first three cohorts, only one infant, born below 28 weeks of gestation, began oral feeding from breast before bottle whereas most of the infants born below 28 weeks of gestation during the last cohort (57.1%) began breastfeeding before bottle-feeding (Table 3). 3.4. Skin-to-skin care The initiation of SSC was analyzed, both by GA and during postnatal age. In the whole study population, the SSC began three weeks (GA) earlier in the last cohort compared to the first cohort and 19 postnatal days earlier. (Table 4). The most prominent change was evident in the most immature infants: in the infants below 28 weeks, SSC began more than five weeks (GA) earlier in the last cohort compared to the first cohort, and 42 postnatal days earlier. The minimum GA at the initiation of SSC was 27.4 weeks during the first cohort compared to 24.6 weeks in the last cohort, and the minimum of postnatal age decreased from 12 to 1 day of age. (Table 4). The number of SSC episodes increased during the first four weeks of life from five episodes in the first cohort to 21 episodes in the last cohort. 3.5. Safety measures The weight gain from birth to discharge increased significantly during the study period from 110 g per week in 2001–2002 to 159 g per week during 2011–2012 (p b 0.001). There was no change in the length
of stay or in the gestational age at the discharge (Table 5). The main trends in the care practices are summarized in Fig. 1. 4. Discussion The hospital care practices of very preterm infants developed during the study period in all categories measured to the direction that supported parent–infant closeness and parental involvement. Especially, there was a significant change in SSC and breastfeeding. We could observe a sequence starting with intensified enteral nutrition leading to shorter use of iv-fluids and incubator care creating an easier access for skin-to-skin care which then created a natural place for early breastfeeding. The weight gain of very preterm infants improved significantly which could have been influenced by both increased skin-toskin care and changes in nutrition. Very early SSC is implemented and studied in the Nordic countries [11]. SSC is safe in infants at 22 to 27 of GA [12,13]. Increased skin-toskin care requires a better appreciation of parent–infant closeness in the care culture of the unit to motivate the staff to learn new skills in this care procedure related to infant transfer, temperature control, infant monitoring, and parent support. In addition there are many societal and cultural factors influencing SSC implementation. A recent report by Reynolds et al. [4] reported that infants below 30 gestational weeks were given SSC, on average, one day per week during the first four weeks after birth, which is comparable to our unit practice during 2001 to 2002. Gonya et al. [14] reported that 80% of preterm infants below 27 weeks were given SSC during the first week of their life comparable to our unit practice in 2011 to 2012. Systematic training
Table 4 The beginning of skin-to-skin care by gestational age in weeks and postnatal age in days, and the amount of SSC episodes during the first four weeks, presented as mean (SD) unless otherwise indicated. n
Age at the beginning of SSC b28 weeks 28–31 weeks ≥32 weeks SSC episodes per first four weeks Age at the beginning of SSC b28 weeks Median (q1, q3) [min, max] 28–31 weeks ≥32 weeks
Years 2001–2002 (n = 72)
Years 2006–2007 (n = 69)
Years 2009–2010 (n = 76)
Years 2011–2012 (n = 78)
p-Value
7.8 (7.2) 15.7 (10.3)⁎ 11.5 (6.8, 24,3) [5.0, 35.0]
29.9 (2.34) 27.2 (1.33) 30.7 (1.31) 33.6 (0.67) 20.9 (0.92) 5.1 (6.1) 7.1 (7.9) 4.0 (3.0, 7.3) [1.0, 31.0]
b0.001 b0.001 b0.001 0.160 b0.001 b0.001 b0.001 b0.001
176 23
42.5 (30.3, 64.5) [12.0, 83.0] 17.5 (11.8)⁎ 7.2 (5.4)⁎
31.0 (1.60) 29.4 (1.47) 31.5 (1.03) 36.0 10.6 (1.05)⁎ 11.4 (9.3) 21.4 (12.0) 20.0 (10.5, 31.8) [7.0, 43.0]
30.9 (2.02)⁎ 28.7 (1.44)⁎ 31.1 (1.15) 34.4 (1.06) 15.6 (0.91)⁎
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32.8 (1.99)⁎ 32.9 (2.84)⁎ 32.3 (1.57)⁎ 34.0 (0.84) 5.0 (0.91)⁎ 24.4 (19.9)⁎ 47.2 (20.3)⁎
8.0 (5.0) 25.0⁎
5.5 (3.4) 4.4 (1.6)
3.9 (4.8) 5.2 (4.5)
b0.001 0.001
74 176 23
⁎ Indicates a significant difference (p b 0.05) between this and the following cohort.
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Table 5 The safety measures indicated by weight gain in grams per week, the length of hospital stay in days and the gestational age at the discharge in weeks presented as mean.
Weight gain (g/week) b28 weeks 28–31 weeks ≥32 weeks The length of hospital stay (days) b28 weeks 28–31 weeks ≥32 weeks GA at discharge b28 weeks 28–31 weeks ≥32 weeks
Years 2001–2002 (n = 72)
Years 2006–2007 (n = 69)
Years 2009–2010 (n = 76)
Years 2011–2012 (n = 78)
p-Value
110⁎ 109 110 116 55.4 91.7 46.6 35.0 37.6 39.4 36.8 38.3
136 131 135 133 57.8 90.0 46.2 33.4 37.4 38.9 36.8 37.6
147⁎ 140 148 129 58.8 95.5 50.2 30.5 38.1 40.1 37.4 38.1
159 155 162 139 58.2 90.7 49.1 27.4 37.6 39.2 37.0 36,6
b0.001 b0.001 b0.001 0.676 0.205 0.929 0.225 0.751 0.195 0.685 0.379 0.225
⁎ Indicates a significant difference (p b 0.05) between this and the following cohort.
program (The Close Collaboration with Parents Training Program) to improve FCC, seemed therefore, to be successful in both increasing the amount of SSC and its earlier initiation. More consistent care practices were also suggested by decreased variation from 11-day range in the first cohort to 6-day range in the last cohort in the initiation of SSC in the most immature infants.
YEAR WEEK
2001-2002
2006-2007
The increase in FCC and SSC, in addition to intensified nutrition, may be another factor to increase growth [15,16] and thereby shorten the need for incubator and warmer bed care. Earlier literature has shown that SSC supports breast-feeding [17,18], which was also seen in our study showing a development towards earlier initiation of breastfeeding. A larger proportion of infants began oral feeding on breast, which has
2009-2010
2011-2012
29 1st SSC
30 End of IV 1st SSC
1st SSC End of IV
31 End of IV
Out of INCUBATOR Out of INCUBATOR
Out of INCUBATOR 32
WARMER BED End of IV 1st SSC 1st BREAST/ BOTTLE feeding
Out of INCUBATOR 33 1st BOTTLE feeding 1st BOTTLE feeding 1st BOTTLE feeding 34
1st BREAST-feeding WARMER BED
WARMER BED 1st BREAST-feeding
1st BREAST-feeding 35
FULL ORAL FEEDING 36
FULL ORAL FEEDING WARMER BED FULL ORAL FEEDING
37
FULL ORAL FEEDING
HOME HOME
HOME HOME
Fig. 1. This figure summarizes the milestones (gestational age at the milestone on the vertical axis) in all study infants in relation to multiple measures presented in details in the tables. The trends towards earlier milestones can be seen by raising steps.
S. Raiskila et al. / Early Human Development 90 (2014) 863–867
been shown to be better compatible with breathing in preterm infants compared to bottle-feeding [19]. Our study showed that the incubator care duration became shorter. The increased growth in our study infants might be one factor making this shift possible because of improved innate thermoregulation. It has been shown to be safe (no effects on weight gain or body temperature) to move a preterm infant from an incubator to a warmer bed at the weight of 1300 to 1500 g [20]. The gestational age at the end of warmer bed care was also lower in the last cohort compared to the first one probably reflecting growth and thermoregulation even better than incubator time. On the other hand, the development towards shorter incubator care may indicate better appreciation of the parents' wish to communicate with their infant without the barrier of incubator wall. Incubator, even if not contraindicating SSC, is an obstacle and it can be easier to initiate SSC without needing to remove the infant from an incubator. In addition, the parents perceive less separation from their infant who is on a warmer bed as touching and speaking to their infant becomes more available without the physical barrier of the incubator wall. In the later cohorts, the duration of parenteral nutrition was shorter compared to the first cohort. IV-line has been reported as a barrier for SSC [21]. In addition, a shorter duration of parenteral nutrition can decrease infant pain, infections, and parental stress [22,23]. The shorter duration of parenteral nutrition was reached by beginning of both parenteral and enteral nutrition during the first day of life and by faster daily increase in the volumes of enteral nutrition. Shorter incubator care, increased SSC, and earlier breastfeeding were safe, without prolonging hospital time for the infants. Previous studies demonstrate that shorter hospitalizations associate with FCC interventions [8] or architectural changes in the unit [7]. In our study unit, the length of hospital stay did not shorten. Compared to the national [24] and international (Vermont Oxford Network) comparison populations, the study unit had shorter than average length of stay already at the beginning of the study. The study design was retrospective using historical cohorts, which limits the conclusions of causalities. One other limitation in this study was that the studied patient charts were mostly handwritten, microfilmed and scanned. The documentation of the care practices was not fully consistent. Therefore, a double check was made regarding the oldest charts, having the least optimal technical quality, to ensure the reliability of the interpretations of the documents. A limitation of the documentation was that it did not include the precise duration of SSC. The safety measures were, however, not affected by inaccuracies. The study sample was relatively large and it covered the whole unit's target population. The data were derived from documentation done “real time” as a part of daily routine, which can be considered more valid than the staff reports of perceived practices. As chart review did not burden the study subjects or the staff, it supports the feasibility of these measures to be used as FCC indicators. Current electronic patient charting systems could be modified to modernize these indicators. 5. Conclusions Significant changes were found in all care practices during the 11-year study period without endangering babies' growth or lengthening the hospital stay. These changes supported and enabled better parent involvement and infant growth. Our results show that less invasive neonatal care practices can be developed allowing more parent-infant closeness. Funding This study was supported by the Turku University Hospital Research Foundation, the South-West Finnish Fund of Neonatal Research, and the Turku University Hospital EVO Fund (13898).
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Conflict of interest statement The authors declare that there are no conflicts of interest.
Acknowledgments We acknowledge our statistician Jaakko Matomäki, M.Sc. and also Robert M. Badeau, Ph.D., Aura Professional English Consulting, Ltd., for the language content editing of this manuscript.
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