Parents are partners in care for their baby and should never be considered as visitors on neonatal units (NNUs).¹ Parents provide nutrition (breast milk) and skin-to-skin care which have significant short and long-term benefits to parents and babies.¹ Parental presence on NNUs is essential to ensure joint decision making about their baby.¹ In the UK, it is common practice for parents to have 24 hour access to NNUs and many have liberal visiting policies allowing siblings and grandparents to visit as well.² Evidence shows better neonatal and parental outcomes, with greater breastfeeding rates, improved weight gain and reduced parental stress and anxiety when parents take an active role in the care of their baby via family-integrated care (FICare).³ Many NNUs in the UK practise at least some elements of FICare.^4,5

In March 2020, a national lockdown was imposed in the UK due to the COVID-19 pandemic. The NHS imposed stringent visiting restrictions to hospitals. These changes were trust-wide and may not have considered the specific needs of babies and parents. Anecdotally, NNUs applied stricter parental access during this time, but there was a range of different policies. As the first wave of the pandemic passed, some units eased restrictions. Bliss, the national neonatal charity, published a position statement in April 2020 reinforcing that parents are not visitors and should have unrestricted access to their babies.⁶ This was supported by the British Association of Perinatal Medicine (BAPM) and the Royal College of Paediatrics and Child Health (RCPCH).¹

Methods

An electronic survey was sent to all 152 neonatal specialty trainee doctors in the UK on SurveyMonkey in October 2020 via email consisting of a mixture of open and closed questions TABLE 1.

TABLE 1 The survey questions.

Results

There were responses from 17 doctors who worked in 17 different neonatal intensive care units (tertiary NNUs). This was a response rate of 11.2%. Geographically these units were spread throughout the UK with one in Wales, one in Scotland and fifteen in England of which four were in London.

All respondents had witnessed a policy change for visitors on their NNU. 80% of units allowed parents to visit at any time of the day, but 60% only allowed one parent at the cot side at a time. However, all units had exceptions to this such as: at admission, if critically unwell and at designated times such as some evenings and weekends. One NNU only allowed parents to visit for two hours a day, but parents could visit together.

No units allowed wider family to visit, although some had exceptions such as if there was a single parent or if the baby was receiving end-of-life care. Prior to COVID-19, grandparents and siblings were also allowed to visit.

94% of the doctors surveyed highlighted at least one significant negative impact on babies and their families due to the changes to parental access. These were wide ranging and are summarised in TABLE 2.

TABLE 2 The negative impacts of limited parental access, as identified by doctors in the survey.

This survey found that 30% of NNUs allowed parents to take off their face masks when they were caring for their baby, 65% did not allow parents to remove their masks and 6% were not sure on their face mask policy.

76% of respondents in this survey did not attribute any transmission of COVID-19 due to visiting on the NNU and the remaining 24% of respondents were not sure if any transmissions of COVID-19 had been attributed to visitors.

Discussion

What access do parents have during the COVID-19 pandemic?

This survey demonstrates that many NNUs in the UK are not following national parental access policy guidance.

Although this survey is limited in the relatively small sample size and relatively low response rate, it does reflect the same results as other research findings. In this survey, 100% of respondents reported a change in the visiting policy and this is similar to studies in the UK and USA.^7,8 In the study by Muniraman et al⁷ parents were asked to complete a questionnaire asking about visiting NNUs during the COVID-19 pandemic, finding that only 62% allowed one parent at the cot side at a time, similar to our 60%. However, this study was also limited by the relatively small number of NNUs which took part.

The cross-sectional survey by Mahoney et al⁸ surveyed 277 neonatal intensive care units, mostly in the USA. They found that NNUs with bays were more likely to have a reduction in parental visiting during COVID-19 compared to single family room units. In the UK, most NNUs are open bays but have a few single rooms for infection prevention purposes. One of the doctors in our survey stated that their restricted visiting policy was due to not being able to adequately socially distance.

This survey also found that the concerns that doctors had about the restricted visiting policy were similar to those expressed by parents in the study by Muniraman et al;⁷ parents reported more stress, reduction in breastfeeding, concerns about bonding and spending less time visiting their baby.⁷ Bliss is currently surveying parents to find out about the impact of the COVID-19 pandemic. The initial findings show that parents are worried about bonding with their baby, feeling isolated, worried about their mental health and concerned about their finances. The full results of this survey are expected to be published later this year. Interestingly, the Babies in Lockdown⁹ study which surveyed over 5,000 parents of babies born during the UK pandemic also found that parents were concerned about bonding with their baby, stress, anxiety and a lack of breastfeeding support. This study was not a study of parents of babies on the NNU and showed a wider impact of the pandemic on families during this time.

Effects on breastfeeding

Providing breast milk to all babies is important, especially those born extremely prematurely.^10,11 It is therefore concerning that our survey and the study by Muniraman et al⁷ found that parental visiting restrictions on NNUs may be reducing breastfeeding. In a study (in press) the closure of expressing rooms on NNUs also hindered the availability of breast milk. National data on this will not be available until later this year. Concern about the impact of breastfeeding during the COVID-19 pandemic was highlighted to the Health Secretaries of the four UK nations in November 2020, which was signed by 21 organisations and over 4,000 health professionals and parents.¹²

Psychological and neurodevelopmental impacts

Parents of premature babies suffer significant psychological distress during their baby’s hospital admission¹³ and this can continue into childhood, having a detrimental effect on the neuro-developmental and behavioural outcomes of the child.¹⁴ FICare and interventions to support parent mental health during the neonatal period can reduce parental stress.³ However, with reduced parental access on the NNU and lack of support from extended families not being able to visit, parents are likely to suffer more stress. The true impact of this on parents and their babies may not be apparent for several years.

Effect of face masks

Since June 2020, it has been mandatory that visitors and staff wear face masks in hospitals in the UK. This survey found that 65% of NNUs did not allow parents to remove their face mask while on the NNU. Face-to-face interaction between parents and their baby is important for brain development, attachment and bonding.¹⁵ We do not know the impact of parents wearing face masks on babies but it may affect the baby’s development of facial processing.¹⁶ There are also concerns that face masks may impact speech, language and communication development and this could have a bigger impact on preterm infants who are already at risk of such problems.¹⁷ It is interesting to note that in the UK, face masks have not been recommended in school because of the negative impact face masks will have on communication, learning and teaching.¹⁸ The lack of recognition of the importance of parents being with their baby in hospital and the impact of face masks on babies may be an example of a ‘baby blind-spot’. This term was coined in a report published by the Parent-Infant Foundation, which found that babies’ needs were overlooked in the COVID-19 response.¹⁹

Does restricting access breach human rights?

There have been no recorded cases of transmission of COVID-19 between parents or by parents to babies or staff on NNUs in any study published globally, including our survey. Article 8 of the Human Rights Act protects your right to respect for your private life, your family life, your home and your correspondence.²⁰ This includes the ‘right to enjoy family relationships without interference from government’.¹⁵ There are situations, such as protecting public safety, that authorities can intervene on. However, any action must be proportionate.¹⁵ Restricting parents spending time with their baby in hospital may be a disproportionate response to the level of risk. This point is similar to that argued by John’s Campaign, a charity who have asked for a judicial review into the decision to restrict visiting in care homes.²¹

What can be done to improve parental access?

It is worrying that babies are being separated from their parents in UK NNUs due to the COVID-19 pandemic, despite national guidance. Allowing parents to spend time with their baby together in a safe way during this pandemic should be a priority in neonatal care. A multi-pronged approach at both a strategic level and local level is required.

At a strategic level, stakeholders need to educate policy makers who may have no experience of neonatal care, that parents are not visitors. The RCPCH, BAPM and Bliss have all released position statements during the pandemic stating that parents are not visitors.²² Unfortunately, despite this national guidance, there are still restrictions on parents attending NNUs across the UK. A more creative approach may be required; media campaigning by the footballer Marcus Rashford reversed government policy on free school meals²³ and public pressure turned around exam result policies in August 2020.²⁴ With new government guidance on how the pandemic restrictions will be lifted over the coming months, it is important to ensure babies’ and families’ needs are understood and reflected in the changes to pandemic rules and that the baby blind-spot does not continue.

At a local level, interventions to improve parental access to NNUs may be easier to apply but this is likely to result in disparity across the UK. Local interventions should empower neonatal staff to support parents to adhere to hygiene and personal protective equipment (PPE) requirements and make practical solutions for social distancing so parents can be with their baby together at the cot side. Many NNUs have been using secure video sharing technology which allows staff to share videos of babies with their parents. Although this may be useful in some circumstances, it cannot replace the physical presence of parents spending time with their baby. It may also be useful for neonatal staff to take a pragmatic approach to their hospital visiting policy. For example, some hospital policies allow parents to be with their baby together for training purposes. Traditionally this would cover skills such as gastrostomy tube training, but could be interpreted to include, for example, how to change their preterm’s nappy or how to comfort them and hold them. TABLE 3 includes a practical example of the steps taken by one NNU to improve parental access.

TABLE 3 Examples of how a NNU spread across two hospitals has increased parental access during the COVID-19 pandemic.

Neonatal care in the UK is organised in geographical areas where hospitals work together to provide care for premature and sick babies.²⁵ If local NNUs work collabor-atively across their neonatal network to improve parental access to NNUs this may reduce disparity across the UK.

Recommendations

1. At unit level, ensure parents are educated about infection prevention including hand washing and PPE. Empower parents to challenge anyone not complying with infection prevention standards.
2. At trust level, educate senior leaders about the importance of parents in neonatal care by sharing the strong evidence for FICare, the developing evidence of harm to families on NNUs during the pandemic and examples of good practice to enable parents to have 24/7 access to the NNU within current social distancing recommendations.
3. At network level, work collaboratively to highlight the importance of 24/7 parental access to NNUs, even during a pandemic. Share best practice of how 24/7 access can be provided within social distancing and infection prevention recommendations.
4. At national level, continue to work with national bodies (eg BAPM, RCPCH, Bliss) so that parents are valued as key members of the baby's care team on the NNU and are never viewed as visitors.
5. At national level, develop new partnerships in the wider society to highlight the vulnerability of babies and the importance of early childhood development to influence society to address the baby blind-spot in national policies.

Conclusion

Babies are being separated from their parents in NNUs due to the COVID-19 pandemic despite national guidance that this should not be happening. This may have negative consequences for the whole family. Easing of national restrictions should not be plagued with a baby blind-spot and a combination of different interventions to increase the time that parents can spend with their baby should be a priority in neonatal care. Approaches to influence policy may need to be creative and innovative. Local approaches may be easier to apply but collaboratively working within networks may improve parental access to NNUs across the UK.