Pregnancy intention in relation to maternal and neonatal outcomes in women with versus without psychiatric diagnoses.

BACKGROUND: Studies have identified adverse maternal and neonatal outcomes for women with psychiatric disorders. Additionally, psychiatric disorders may pose an increased risk for unintended pregnancies (UPs) which in turn may also impact negatively on outcomes. The present study aims to compare the incidence of UPs in women with versus without current/past psychiatric diagnoses and investigates whether psychiatric history modifies the relation between delivery outcomes in women with and without UPs. METHODS: A retrospective cohort was compiled of women who gave birth in a large hospital in Amsterdam, the Netherlands. Women ≥18 years old with singleton pregnancies and birth registrations in the electronic patient file during January 1, 2015 to March 1, 2020 were included. Patient characteristics (including pregnancy intention and psychiatric history), maternal (gestational diabetes, mode of delivery) and neonatal outcomes (e.g., gestational age [GA], birthweight and Apgar scores) were registered by health care providers in hospital charts. Incidence of UPs was compared between women with versus without current/past psychiatric diagnoses. Maternal and neonatal outcomes were compared between women with versus without UPs with linear or logistic regression models adjusted for relevant confounders with an interaction term for UP with current/past psychiatric diagnoses. RESULTS: We included 1219 women with and 1093 women without current/past psychiatric diagnoses. Current/past psychiatric diagnoses were significantly associated with UPs after adjustment for confounders (39.0% vs. 29.6%, OR 1.56, CI 1.23-2.00, p < 0.001). In sub-analyses, women with depressive (OR 1.67, CI 1.24-2.26, p = 0.001), personality (OR 2.64, CI 1.38-5.11, p = 0.004) and substance-related and addictive disorders (OR 4.29, CI 1.90-10.03, p = 0.001) had higher odds of UPs compared to women without current/past psychiatric diagnoses. Amongst women with UPs, current/past psychiatric diagnoses did not modify maternal or neonatal outcomes, except for GA at delivery as women with both UPs and current/past psychiatric diagnosis had a 2.21-day higher mean GA at delivery than women in the reference group (p-value interaction = 0.001). CONCLUSIONS: Current/past psychiatric diagnoses are associated with a higher odd of UPs. In our sample, maternal and neonatal outcomes were comparable for women with and without UPs and these results were similar for women with and without current/past psychiatric diagnoses, except for GA at delivery. Although our study is limited by several factors, we found that women with current/past psychiatric diagnoses, irrespective of pregnancy planning status, do not have more adverse maternal or pregnancy outcomes. Increased efforts are needed to ensure that psychoeducation and conversations about pregnancy planning and UPs are available for women with current/past psychiatric diagnoses.

The conversation about family planning and desire for children in mental healthcare: Patients' perspective versus Professionals' perspective in a mixed methods study.

BACKGROUND: Reproductive health and mental health are intertwined, but studies investigating family planning needs and desire for children in mental healthcare are scarce. METHODS: We studied the experiences of (former) patients, those with close relationships with the (former) patients (close ones) and mental health professionals (MHP) on discussing family planning and desire for children in mental healthcare. We combined quantitative (two nationwide surveys) and qualitative data (four focus groups) in a mixed-methods approach with sequential analytical design. RESULTS: Combined data from focus groups (n = 19 participants) and two surveys (n = 139 MHPs and n = 294 (former) patients and close ones) showed that a considerable group of MHPs (64.0%), patients (40.9%) and close ones (50.0%) found that family planning should be discussed by a psychiatrist. However, several obstacles impeded a conversation, such as fear of judgment, lack of time and knowledge and limited opportunity for in-depth exploration of life themes in therapeutic relationships. CONCLUSIONS: To increase the autonomy of patients in discussing family planning, we suggest MHPs explore the desire to discuss family planning with all patients in the reproductive phase of life, prior to discussing contraceptive care. MHPs should receive education about psychiatric vulnerability in relation to family planning and desire for children, and patients and close ones should be empowered to initiate a conversation themselves.

'Not a goal, but a given': Neonatal care participation through parents' perspective, a cross-sectional study.

AIM: To explore parents' perspectives regarding participation in neonatal care, with focus on the family integrated care (FICare) model utilised as a tool to enhance parent-infant closeness. Additionally, we describe experiences in different architectural settings. METHODS: An online survey, categorised by four FICare pillars, was distributed through social media to parents of newborns hospitalised to Dutch neonatal wards between 2015 and 2020. Quantitative findings were summarised using descriptive statistics, while open-ended responses were thematically analysed. RESULTS: Among the 344 respondents (98% mothers), most reported feeling involved in care (315/340). However, 79% also felt separated from their infant (265/337). Irrespective of architectural settings, parents reported incomplete implementation of FICare pillars: 14% was invited to educational sessions (parent education), 51% discussed family-specific care plans (staff education), 21% was facilitated in connecting with veteran parents (psychosocial support) and 22% received couplet-care (environment). Although 65% of parents were invited to attend clinical rounds, 32% actively participated in decision making. Thematic analysis revealed fundamentals for feeling welcome on the ward, peer-to-peer support, psychosocial support and participation in clinical rounds. CONCLUSION: Overall, parents expressed satisfaction with participation in neonatal care. However, structural implementation of FICare lacks. Regardless of architecture, expanding parent participation beyond presence requires attention.

Rebalancing of professional identity roles in an integrated maternity and neonatal care setting designed to increase parent autonomy: a qualitative study among health professionals.

This case-based qualitative study explored the professional identity as experienced by health professionals working in an integrated maternal-neonatal ward when their practice changed from a "paternalistic" model, in which physicians and nurses were in charge, to a shared or "consumerist" model, to increase parent autonomy. We analyzed transcripts of focus group discussions and interviews with 60 health professionals on their experiences with empowering parents and described factors associated with themes of professional identity. The changes most affecting professional identity were the constant proximity of parents to their newborns and the single-family room design. These changes influenced three themes of professional identity: (1) connectedness and relationships (2) communication, and (3) competencies. A fourth theme, values, beliefs, and ethics, affected how the health professionals coped with the changes in the first three themes. When empowering parents of newborns in a hospital setting, health professionals experience beneficial as well as threatening shifts in their professional identities. Values, beliefs, and ethics associated with family integrated care helped health professionals to embrace their new roles, but other values, beliefs and ethics could create barriers. Continuous professional identity development in a patient-inclusive team is a topic for future research.

Lower versus Traditional Treatment Threshold for Neonatal Hypoglycemia.

BACKGROUND: Worldwide, many newborns who are preterm, small or large for gestational age, or born to mothers with diabetes are screened for hypoglycemia, with a goal of preventing brain injury. However, there is no consensus on a treatment threshold that is safe but also avoids overtreatment. METHODS: In a multicenter, randomized, noninferiority trial involving 689 otherwise healthy newborns born at 35 weeks of gestation or later and identified as being at risk for hypoglycemia, we compared two threshold values for treatment of asymptomatic moderate hypoglycemia. We sought to determine whether a management strategy that used a lower threshold (treatment administered at a glucose concentration of <36 mg per deciliter [2.0 mmol per liter]) would be noninferior to a traditional threshold (treatment at a glucose concentration of <47 mg per deciliter [2.6 mmol per liter]) with respect to psychomotor development at 18 months, assessed with the Bayley Scales of Infant and Toddler Development, third edition, Dutch version (Bayley-III-NL; scores range from 50 to 150 [mean {±SD}, 100±15]), with higher scores indicating more advanced development and 7.5 points (one half the SD) representing a clinically important difference). The lower threshold would be considered noninferior if scores were less than 7.5 points lower than scores in the traditional-threshold group. RESULTS: Bayley-III-NL scores were assessed in 287 of the 348 children (82.5%) in the lower-threshold group and in 295 of the 341 children (86.5%) in the traditional-threshold group. Cognitive and motor outcome scores were similar in the two groups (mean scores [±SE], 102.9±0.7 [cognitive] and 104.6±0.7 [motor] in the lower-threshold group and 102.2±0.7 [cognitive] and 104.9±0.7 [motor] in the traditional-threshold group). The prespecified inferiority limit was not crossed. The mean glucose concentration was 57±0.4 mg per deciliter (3.2±0.02 mmol per liter) in the lower-threshold group and 61±0.5 mg per deciliter (3.4±0.03 mmol per liter) in the traditional-threshold group. Fewer and less severe hypoglycemic episodes occurred in the traditional-threshold group, but that group had more invasive diagnostic and treatment interventions. Serious adverse events in the lower-threshold group included convulsions (during normoglycemia) in one newborn and one death. CONCLUSIONS: In otherwise healthy newborns with asymptomatic moderate hypoglycemia, a lower glucose treatment threshold (36 mg per deciliter) was noninferior to a traditional threshold (47 mg per deciliter) with regard to psychomotor development at 18 months. (Funded by the Netherlands Organization for Health Research and Development; HypoEXIT Current Controlled Trials number, ISRCTN79705768.).

In-hospital education of parents of newborns may benefit from competency-based education: A qualitative focus group and interview study among health professionals.

AIMS/OBJECTIVES: The aim of this study was to appraise health professionals' self-reported practices in educating parents of hospitalised newborns from the perspective of competency-based education and to identify areas for improvement of parental learning. BACKGROUND: Patient education is essential to achieve autonomy in parents of hospitalised newborns. The literature provides descriptions of the use of various components of competency-based education in patient education. This suggests that competency-based education is a valuable concept for patient education. DESIGN: A case-based qualitative study. METHODS: Three focus group discussions were conducted and 28 semi-structured interviews with 45 health professionals who practice in a hospital setting that is designed to empower parents. The data were analysed with a framework analysis approach, using a framework of competency-based education themes for a combined inductive and deductive content data analysis. The recommendations of the Standards for Reporting Qualitative Research checklist were followed. FINDINGS: Two themes of competency-based education emerged as evidently operationalised: (1) 'Learning climate' and (2) 'Role modeling'. Five themes emerged as incompletely operationalised: (1) 'Parent curriculum based on inter-professional consensus'; (2) 'Transparency about the competencies needed'; (3) 'Access to teaching'; (4) 'Assessing and reporting results'; and (5) 'Proficiency statements based on autonomy expectations'. Two themes did not emerge: (1) 'Empowering parents to be active learners' and (2) 'Evaluation and improvement of the education program'. CONCLUSIONS: Parent education is at risk of being merely on a master-apprentice model and may be more effective if it is designed on competency-based education principles. Identified areas for improvement are empowering parents to be 'active learners' and by involving them in the evaluation and improvement of the educational program. Parent education in neonatal health care may benefit from an appraisal based on competency-based education themes. RELEVANCE TO CLINICAL PRACTICE: Appraising parent education based on competency-based education principles is feasible for improving the learning process towards parent autonomy.

Severity of Bronchopulmonary Dysplasia and Neurodevelopmental Outcome at 2 and 5 Years Corrected Age.

OBJECTIVE: To evaluate the association between bronchopulmonary dysplasia (BPD) severity and risk of neurodevelopmental impairment (NDI) at 2 years and 5 years corrected age and to examine whether this association changes over time. STUDY DESIGN: This single-center retrospective cohort study included patients with a gestational age <30 weeks surviving to 36 weeks postmenstrual age, divided into groups according to BPD severity. NDI was defined as having cognitive or motor abilities below -1 SD, cerebral palsy, or a hearing or a visual impairment. The association was assessed using a multivariate logistic regression model analysis, adjusting for known confounders for NDI, and mixed-model analysis. RESULTS: Of the 790 surviving infants (15% diagnosed with mild BPD, 9% with moderate BPD, and 10% with severe BPD), 88% and 82% were longitudinally assessed at 2 years and 5 years corrected age, respectively. The mixed-model analysis showed a statistically significant increase in NDI at all levels of BPD severity compared with infants with no BPD, and a 5-fold increased risk in NDI was seen from 2 years to 5 years corrected age in all degrees of BPD severity. The strength of this association between NDI and BPD severity did not change over time. CONCLUSIONS: Increased BPD severity is associated with increased risk of NDI at both 2 years and 5 years corrected age. The absolute incidence of NDI increased significantly from 2 years to 5 years corrected age for all BPD severity categories, but this increased risk was similar at both time points in each category.

Family integrated care in single family rooms for preterm infants and late-onset sepsis: a retrospective study and mediation analysis.

BACKGROUND: During hospital stay after birth, preterm infants are susceptible to late-onset sepsis (LOS). OBJECTIVE: To study the effect of family integrated care in single family rooms (SFRs) compared to standard care in open bay units (OBUs) on LOS. Peripheral or central venous catheters (PVCs/CVCs) and parenteral nutrition (PN) were investigated as potential mediators. Secondary outcomes were length of stay, exclusive breastfeeding at discharge, and weight gain during hospital stay. METHODS: Single-center retrospective before-after study with preterm infants admitted ≥3 days. RESULTS: We studied 1,046 infants (468 in SFRs, 578 in OBUs, median gestational age 35 weeks). SFRs were associated with less LOS (adjusted odds ratio (OR) 0.486, 95% confidence interval (CI): 0.293; 0.807, p = 0.005). PVCs (indirect effect -1.757, 95% CI: -2.738; -1.068), CVCs (indirect effect -1.002, 95% CI: -2.481; 0.092), and PN (indirect effect -1.784, 95% CI: -2.688; -1.114) were possible mediators of the effect. PN was the main mediator of the effect of SFRs on LOS. We found shorter length of stay (median length of stay in SFRs 10 days and in OBUs 12 days, adjusted ß -0.088, 95% CI: -0.159; -0.016, p = 0.016), but no differences in weight gain or exclusive breastfeeding at discharge. CONCLUSIONS: SFRs were associated with decreased incidences of LOS and shorter length of hospital stay. The positive effect of SFRs on LOS was mainly mediated through a decreased use of PN in SFRs. IMPACT: Family integrated care (FICare) in single family rooms for preterm infants was associated with less late-onset sepsis events during hospital stay and a shorter length of hospital stay after birth. FICare in single family rooms was associated with less use of peripheral or central venous catheters and parenteral nutrition. Mediation analysis provided insights into the mechanisms underlying the effect of FICare in single family rooms on late-onset sepsis and helped explain the differences observed in late-onset sepsis between FICare in single family rooms and open bay units. The reduction in late-onset sepsis in FICare in single family rooms was mediated by a reduced use of intravenous catheters and parenteral nutrition.

Risk Factors for Neurodevelopmental Impairment at 2- and 5-Years Corrected Age in Preterm Infants with Established Bronchopulmonary Dysplasia.

INTRODUCTION: The objective of this study was to identify risk factors for neurodevelopmental impairment (NDI) at 2- and 5-years corrected age (CA) in a cohort of preterm infants with established bronchopulmonary dysplasia (BPD). METHODS: This single-center retrospective cohort study included infants born between 2009 and 2016 at a gestational age (GA) <30 weeks with moderate or severe BPD at 36 weeks' postmenstrual age. Perinatal characteristics, (social) demographics, and comorbidities were collected from the electronic patient records. Odds ratios for NDI were calculated with univariate and multivariate logistic regression analyses adjusting for potential confounders. RESULTS: Of the 602 eligible infants, 123 infants were diagnosed with BPD. NDI was present in 30.3% and 56.1% at 2- and 5-years CA, respectively. The only independent risk factors associated with NDI in the multivariate analyses were birthweight (adjusted odds ratio [aOR] 0.74, 95% CI 0.57-0.95; aOR 0.70, 95% CI 0.54-0.91, respectively), small for GA (SGA) (aOR 3.25, 95% CI 1.09-9.61; aOR 5.44, 95% CI 1.62-18.2, respectively) at both time points, and male gender at 5-years CA (OR 2.49, 95% CI 1.11-5.57). CONCLUSION: Birthweight and SGA are independent risk factors for NDI at 2- and 5-years CA and male gender at 5-years CA in preterm infants with BPD. In contrast, well-known other risk factors for NDI in the general population of preterm infants, such as GA, maternal education, and neonatal comorbidities were not independently associated with NDI.

Association between bronchopulmonary dysplasia severity and its risk factors and long-term outcomes in three definitions: a historical cohort study.

OBJECTIVE: To compare the association of the severity categories of the 2001-National Institutes of Health (NIH), the 2018-NIH and the 2019-Jensen bronchopulmonary dysplasia (BPD) definitions with neurodevelopmental and respiratory outcomes at 2 and 5 years' corrected age (CA), and several BPD risk factors. DESIGN: Single-centre historical cohort study with retrospective data collection. SETTING: Infants born between 2009 and 2015 at the Amsterdam University Medical Centers, location Amsterdam Medical Center. PATIENTS: Preterm infants born at gestational age (GA) <30 weeks and surviving up to 36 weeks' postmenstrual age. INTERVENTIONS: Perinatal characteristics, (social) demographics and comorbidities were collected from the electronic patient records. MAIN OUTCOME MEASURES: The primary outcomes were neurodevelopmental impairment (NDI) or late death, and respiratory morbidity at 2 and 5 years' CA. Using logistic regression and Brier scores, we investigated if the ordinal grade severity is associated with incremental increase of adverse long-term outcomes. RESULTS: 584 preterm infants (median GA: 28.1 weeks) were included and classified according to the three BPD definitions. None of the definitions showed a clear ordinal incremental increase of risk for any of the outcomes with increasing severity classification. No significant differences were found between the three BPD definitions (Brier scores 0.169-0.230). Respiratory interventions, but not GA, birth weight or small for GA, showed an ordinal relationship with BPD severity in all three BPD definitions. CONCLUSION: The severity classification of three BPD definitions showed low accuracy of the probability forecast on NDI or late death and respiratory morbidity at 2 and 5 years' CA, with no differences between the definitions.

Type of infectious disease affects glucose metabolism and liver glycogen content in Surinamese children: malaria vs. pneumonia.

BACKGROUND AND AIM: Fasting is an important risk factor for hypoglycemia in children with malaria or pneumonia. Young children are more at risk because of impaired endogenous glucose production presumably due to smaller liver glycogen stores. The aim of this study was to measure the effect of a bolus of glucagon on glucose kinetics, as an indicator of glycogen content, in fasted children with malaria and pneumonia. METHODS: After a 16-h controlled fast, plasma glucose concentration and endogenous glucose production were measured using [6,6-2H2]glucose in six children with severe malaria and 12 children with severe pneumonia who were 1-5 years of age before and after a bolus glucagon. RESULTS: Basal glucose concentration and endogenous glucose production were higher in children with malaria, p=0.034 and p=0.010, respectively. After glucagon, the increase in the plasma glucose concentration was higher in children with malaria (52±26% vs. 31±23%, p=0.029). Also, the increase in glucose production was higher in children with malaria (106±42% vs. 70±52%, p=0.023). There were no differences in the fasting duration or duration of illness. CONCLUSIONS: This is the first study to show infectious disease-related differences in the adaptation of glucose metabolism to fasting in young children. It was found that basal glucose concentration and endogenous glucose production were higher in children with malaria. The increase in plasma glucose concentration and endogenous glucose production in response to glucagon was higher in children with malaria, indicating smaller glycogen stores in children with pneumonia.

Fasting predisposes to hypoglycemia in Surinamese children with severe pneumonia, and young children are more at risk.

The objective of this study was to investigate glucose kinetics during controlled fasting in children with severe pneumonia. Plasma glucose concentration, endogenous glucose production and gluconeogenesis were measured in 12 Surinamese children (six young: 1-3 years, six older: 3-5 years) with severe pneumonia during a controlled 16 h fast using stable isotopes [6,6-(2)H2]glucose and (2)H2O at a hospital-based research facility. On admission, the glucose concentrations were comparable in both groups: young children: 5.1 ± 1.3 mmol/l, older children: 4.8 ± 0.6 mmol/l, p = 0.685, with a decrease during the first 8 h of fasting in the young children only to 3.6 ± 0.5, p = 0.04. Glucose production was comparable in both groups: young: 24.5 ± 8.3, older: 24.9 ± 5.9 µmol/kg(•)min, p = 0.926. Between 8 and 16 h of fasting, the glucose concentration decreased comparably in both groups (young: - 0.9 ± 0.7, p = 0.004; older: -1.0 ± 0.4 mmol/l, p = 0.001), as did glucose production (young: -6.8 ± 6.3, p = 0.003; older: -5.3 ± 3.4 µmol/kg(•)min, p = 0.001). Gluconeogenesis decreased in young children only: -5.0 ± 7.4, p = 0.029. We conclude that fasting predisposes to hypoglycemia in children with severe pneumonia. Young children are more at risk than older children. Glucose production is an important determinant of the plasma glucose concentration in young children with pneumonia, indicating an inability to reduce glucose usage. Our results are largely in agreement with the literature on the adaptation of glucose metabolism in children with malaria, although there seem to be disease-specific differences in the regulation of gluconeogenesis.

Incidence and risk factors for early hypoglycemia in very preterm infants: The hyporisk study.

PURPOSE: To determine incidence, timing and potential risk factors associated with hypoglycemia in the first day of life in very premature infants. METHODS: Retrospective cohort study including all infants born before 32 weeks of gestation between 1 July 2017 and 31 December 2020 in the Erasmus MC Sophia Children's Hospital (Rotterdam, the Netherlands). Excluded were those who died within 24 h after birth or with no glucose data available. We collected maternal and neonatal characteristics from patient files, as well as all routine glucose values for the first 24 h. Hypoglycemia was defined as blood glucose value below 2.6 mmol/L. Risk factors were selected using univariable and multivariable logistic regression with stepwise backward elimination. Kaplan-Meier survival analysis was performed to examine time-to-event after birth. RESULTS: Of 714 infants included (median gestational age 29.3 weeks, mean weight 1200 g), 137 (19%) had at least one episode of hypoglycemia, with a median time-to-event of 126 min [95%-CI 105-216]. Relevant independent risk factors for hypoglycemia included two maternal (insulin-dependent diabetes [OR 2.8; 95%-CI 1.3-6.1]; antenatal steroid administration [OR 1.7, 95%-CI 1.1-2.7]), and four neonatal factors (no IV-access in delivery room [OR 6.1, 95% CI-3.2-11.7], gestational age in weeks [OR 1.3, 95% CI-1.2-1.5], small-for-gestational-age [OR 2.6, 95%-CI 1.4-4.8], and no respiratory support (versus non-invasive support) [OR 2.3, 95%-CI 1.0-5.3]). CONCLUSION: Six risk factors were identified for hypoglycemia in the first 24 h of life in very preterm infants, that can be used for development of prediction models, risk-based screening and updating guidelines.

Using expert opinion rounds to develop valid and realistic manipulations for experimental video-vignette research: Results from a study on clinicians' (un)reasonable argumentative support for treatment decisions in neonatal care.

OBJECTIVE: To develop valid and realistic manipulations for video-vignette research using expert opinion rounds, in preparation of an experimental study on clinicians' (un)reasonable argumentative support for treatment decisions in neonatal care. METHODS: In three rounds, N = 37 participants (parents/clinicians/researchers) provided feedback on four video-vignette scripts and completed listing, ranking, and rating exercises to determine which (un)reasonable arguments clinicians may provide to support treatment decisions. RESULTS: Round 1: participants deemed the scripts realistic. They judged that, on average, clinicians should provide two arguments for a treatment decision. They listed 13-20 reasonable arguments, depending on the script. Round 2: participants ranked the two most salient, reasonable arguments per script. Round 3: participants rated the most plausible, unreasonable arguments from a predefined list. These results guided the design of 12 experimental conditions. CONCLUSION: Expert opinion rounds are an effective method to develop video-vignettes that are theoretically sound and ecologically realistic and offer a powerful means to include stakeholders in experimental research design. Our study yielded some preliminary insights into what are considered prevalent (un)reasonable arguments for clinicians' treatment plans. PRACTICE IMPLICATIONS: We provide hands-on guidelines on involving stakeholders in the design of video-vignette experiments and the development of video-based health communication interventions - both for research and practice.

Experiences with Family Planning amongst Persons with Mental Health Problems: A Nationwide Patient Survey.

High rates of unintended pregnancies in patients with mental health problems reflect the unmet need for tailored family planning. This study aims to explore aspects of family planning that are especially challenging for patients experiencing health problems by obtaining the perspective of (former) patients and those with close relationships with the (former) patients. In August 2021, members of a Dutch national mental health panel, consisting of (former) patients and close ones, were invited to respond to a 34-question online survey that included questions on four domains: reproductive history, decision making, parenting, and sexuality. This study has revealed the severe and adverse impact of mental health problems across all of the four domains of reproductive health and family planning, which the questions specifically targeted. Based on these results, we recommend discussing family planning with all patients experiencing or at risk for mental health problems and their partners. These discussions should address a desire to have children, (involuntary) childlessness, uncertainties about parenting and sexuality, while remaining considerate of experienced taboos.

Collaborating to Improve Neonatal Care: ParentAl Participation on the NEonatal Ward-Study Protocol of the neoPARTNER Study.

Parents are often appointed a passive role in the care for their hospitalised child. In the family-integrated care (FICare) model, parental involvement in neonatal care is emulated. Parental participation in medical rounds, or family-centred rounds (FCR), forms a key element. A paucity remains of randomised trials assessing the outcomes of FCR (embedded in FICare) in families and neonates, and outcomes on an organisational level are relatively unexplored. Likewise, biological mechanisms through which a potential effect may be exerted are lacking robust evidence. Ten level two Dutch neonatal wards are involved in this stepped-wedge cluster-randomised trial FCR (embedded in FICare) by one common implementation strategy. Parents of infants hospitalised for at least 7 days are eligible for inclusion. The primary outcome is parental stress (PSS:NICU) at discharge. Secondary outcomes include parental, neonatal, healthcare professional and organisational outcomes. Biomarkers of stress will be analysed in parent-infant dyads. With a practical approach and broad outcome set, this study aims to obtain evidence on the possible (mechanistic) effect of FCR (as part of FICare) on parents, infants, healthcare professionals and organisations. The practical approach provides (experiences of) FICare material adjusted to the Dutch setting, available for other hospitals after the study.

An international study on implementation and facilitators and barriers for parent-infant closeness in neonatal units.

Importance: Parent-infant closeness and active parent participation in neonatal care are important for parent and infant health. Objective: To give an overview of current neonatal settings and gain an in-depth understanding of facilitators and barriers to parent-infant closeness, zero-separation, in 19 countries. Methods: Neonatal intensive care unit (NICU) professionals, representing 45 NICUs from a range of geographic regions in Europe and Canada, were purposefully selected and interviewed June-December 2018. Thematic analysis was conducted to identify, analyze and report patterns (themes) for parent-infant closeness across the entire series of interviews. Results: Parent-infant separation during infant and/or maternity care is very common (42/45 units, 93%), despite the implementation of family integrated care (FICare) practices, including parent participation in medical rounds (17/45, 38%), structured education sessions for parents (16/45, 36%) and structured training for healthcare professionals (22/45, 49%). NICU professionals encountered four main themes with facilitators and barriers for parent-infant closeness on and between the hospital, unit, staff, and family level: Culture (jointly held characteristics, values, thinking and behaviors about parental presence and participation in the unit), Collaboration (the act of working together between and within different levels), Capacities (resources and policies), and Coaching (education to acquire and transfer knowledge and skills). Interpretation: Implementing parent-infant closeness in the NICU is still challenging for healthcare professionals. Further optimization in neonatal care towards zero-separation and parent-infant closeness can be achieved by enforcing the 'four Cs for Closeness': Culture, Collaboration, Capacities, and Coaching.

Association of a Family Integrated Care Model With Paternal Mental Health Outcomes During Neonatal Hospitalization.

Importance: During newborn hospitalization in the neonatal unit, fathers often feel anxious and excluded from their child's caregiving and decision-making. Few studies and interventions have focused on fathers' mental health and their participation in neonatal care. Objective: To study the association of a family integrated care (FICare) model (in single family rooms with complete couplet-care for the mother-newborn dyad) vs standard neonatal care (SNC) in open bay units with separate maternity care with mental health outcomes in fathers at hospital discharge of their preterm newborn and to study whether parent participation was a mediator of the association of the FICare model on outcomes. Design, Setting, and Participants: This prospective, multicenter cohort study was conducted from May 2017 to January 2020 as part of the fAMily Integrated Care in the Neonatal Ward Study, at level-2 neonatal units in the Netherlands (1 using the FICare model and 2 control sites using SNC). Participants included fathers of preterm newborns admitted to participating units. Data analysis was performed from January to April 2021. Exposure: FICare model in single family rooms with complete couplet-care for the mother-newborn dyad during maternity and/or neonatal care. Main Outcomes and Measures: Paternal mental health was measured using the Parental Stress Scale: NICU, Hospital Anxiety and Depression Scale, Post-partum Bonding Questionnaire, Perceived (Maternal) Parenting Self-efficacy Scale, and satisfaction with care (EMpowerment of PArents in THe Intensive Care-Neonatology). Parent participation (CO-PARTNER tool) was assessed as a potential mediator of the association of the FICare model with outcomes with mediation analyses (prespecified). Results: Of 309 families included in the fAMily Integrated Care in the Neonatal Ward Study, 263 fathers (85%) agreed to participate; 126 fathers were enrolled in FICare and 137 were enrolled in SNC. In FICare, 89 fathers (71%; mean [SD] age, 35.1 [4.8] years) responded to questionnaires and were analyzed. In SNC, 93 fathers (68%; mean [SD] age, 36.4 [5.5] years) responded to questionnaires and were analyzed. Fathers in FICare experienced less stress (adjusted ß, -10.02; 95% CI, -15.91 to -4.13; P = .001) and had higher participation scores (adjusted odds ratio, 3.424; 95% CI, 0.860 to 5.988; P = .009) compared with those in SNC. Participation mediated the beneficial association of the FICare model with fathers' depressive symptoms (indirect effect, -0.051; 95% CI, -0.133 to -0.003) and bonding with their newborns (indirect effect, -0.082; 95% CI, -0.177 to -0.015). Conclusions and Relevance: These findings suggest that the FICare model is associated with decreased paternal stress at discharge and enables fathers to be present and participate more than SNC, thus improving paternal mental health. Supporting fathers to actively participate in all aspects of newborn care should be encouraged regardless of architectural design of the neonatal unit.