Pandemic Challenges in a Neonatal Intensive Care Unit
ByJacci Siebert, 1 August 2020
Jacci Siebert is an Occupational Therapist (OT) of 26 years having graduated in 1994 from the University of the Witwatersrand in Johannesburg, South Africa. After 5 years working in a variety of settings in South Africa and the United States, she moved to the UK where she has worked in paediatric settings, community, education and private practice and eventually specialising in sensory processing and Autism Spectrum Condition in a special school setting.
Last year, she began a new journey covering acute paediatrics including Neonatal Intensive care at Basildon University Hospital in Essex. She covers in-patient children’s wards, out-patient oncology and rheumatology clinics as well as a 21 cot secondary level NICU. Jacci tells us how COVID-19 has been impacting her practice within this setting.
The COVID-19 pandemic continues to impact on the services we are able to offer. Initially our team, (which consists of 3 paediatric physiotherapists, one band 6 OT and myself, a band 7 OT), needed to reshuffle and triage our caseloads and assess the risks to our patients. This meant putting all our out-patients on a waiting list with the exception of children who have an oncology diagnosis.
Our band 6 OT and PT were redeployed to adult wards due to their more recent skills and competencies in working with respiratory and adult rehab clients. Fortunately, we were able to maintain aspects of our in-patient service including on our NICU while other hospitals have reported that they have had their therapy teams pulled out of NICU.
Many NICUs globally have put restrictions on parental access to their premature or sick babies due to the COVID-19 social distancing measures. Our NICU, having previously had unrestricted parental access for both mothers and fathers, are now implementing a staggered visiting time schedule of 3 hours per day, where either the mother or the father can visit but not together. For the premature and sick babies, who can frequently spend as long as 3-4 months on the unit, limiting parental access will have far reaching effects, as family involvement is essential for their neurodevelopmental outcomes.
Prematurity is regarded as an Adverse Childhood Experience (A.C.E) due to babies being separated from their mothers and as well as the trauma they experience as a result of necessary medical care. A.C.E.’s have long term physical and mental health consequences due to epigenetic changes to chromosome expression which can occur as a result. Separation from their mother may be the most profound source of stress in the hospitalised infant.
Skin to skin contact is known to significantly reduce pain and stress in premature and sick babies (Casper et al. 2018). It is the central tenant of neuroprotective care and the most healing environment for premature babies outside the womb, effectively allowing premature infants to continue their gestation. Daily skin to skin contact is considered as vital as any medical assistance the baby might be receiving. Its benefits include better weight gain and therefore earlier discharge from hospital, as babies use less energy to maintain a calm state and a constant temperature during skin to skin contact. It encourages breastfeeding and stabilises heart rate and breathing, which helps maintain good oxygenation. Casper et al. (2018) found that the benefits of skin to skin are dose dependent in very preterm infants. Prolonged daily skin-to-skin contact (more than 3 hours) was associated with a lower incidence of hospital acquired infections and better rates of breastfeeding.
The quality of the parent-infant bond, which is already altered by the NICU experience, is an important factor in determining the baby’s quality of life after discharge. For mothers and fathers, time spent watching their baby will help them to tune into their baby’s cues assisting them to effectively comfort and bond with them. When time is limited or capped this can impact on the bonding and attunement process. When parents and babies cuddle, they both produce Oxytocin which is a hormone involved in attachment and bonding. It strengthens trust and closeness, stimulates well-being, reduces the effects of stress, decreases sensitivity to pain, decreases inflammation and stimulates growth and healing (Uvnäs-Moberg et al. 2014).
While some NICUs only ever restricted fathers not mothers, other NICUs have been reported to have implemented a 1 hour per day parental access. Many NICUs are hopefully now lifting their restrictions on parental access and Bliss has published a statement on parental access during COVID-19 encouraging NICUs to do everything they possibly can to ensure parents are not restricted in their access to their baby and are included as a member of the NICU team.
As our NICU has limited space, it is unlikely that we will go back to unlimited parental access in the near future, which is very frustrating for the neonatal professionals who understand what this means for the outcomes of the babies who spend a long time with us. The therapy team has produced a leaflet for all NICU parents about bonding and attachment and how they can make the most of their time in NICU. We are able to provide advice and parent education about neuroprotective care for any babies born before 32 weeks or those with Intraventricular Haemorrhage (IVH grade 3-4), Hypoxic Ischaemic encephalopathy (HIE grade 2-4) or genetic conditions. We have had some ideas about how we might provide further coaching for the affected babies and their parents covering topics such as ‘Serve and Return’ responsiveness, ‘Goodness of Fit’ reciprocity and co-regulation, however this is still very much in its infancy and at this stage we are very much going baby by baby.
