Introduction

To say the COVID-19 pandemic has upended the delivery of healthcare in the United States and the rest of the world would be a gross understatement. While the neonatal intensive care unit (NICU) has escaped, for the most part, the ramifications of having patients critically ill with COVID-19, the impact of this pandemic snaked its way through row upon row of incubators [31]. Hall et al. recommend offering peer support to NICU families as one of the primary components of family-centered care [32]. Most studies evaluating peer support in the NICU have looked at in-person programs moderated by former NICU parents. However, with visitation restrictions and recommendations for social distancing in the era of COVID-19, it is unlikely that these support programs can meet in or outside of the hospital. With that, families may look to internet support groups even more. Benefits to online support groups include the ability to access groups specific to their needs (i.e., congenital anomalies, genetic disorders) and on their own time [32]. In addition, parents can post anonymously, there may be decreased biases based on gender or socioeconomic status, and support can continue beyond hospitalization [32,33,34,35]. Of course, internet support groups can have drawbacks. Nonsupportive posts, misinformation, or unreliable data may be shared, especially if the group is not followed by experienced or knowledgeable moderators [32, 36]. Some online support groups can be found in Table 1 and additional support groups sorted by country can be found at the European Foundation for the Care of Newborn Infants website. Additional strategies for families while away from their infant include journaling and tracking NICU milestones and developments [37].

Table 1 NICU parental/caregiver online support groups.
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Supporting families in the NICU

When parents are allowed to visit in the NICU, supporting them in the moment is imperative. Studies have shown that in general, parents do feel supported in the NICU from both nursing and medical providers [38]. However, there is consistent desire for more information on their child as well as emotional support [38,39,40]. In times of reduced visitation, how do we enhance psychosocial support of NICU parents? Hall et al. provide several recommendations that can be quickly implemented and/or augmented (Table 2) [41]. Ensuring that mental health professionals such as psychologists and social workers continue to work with families is imperative. Pastoral or religious care personnel can also supplement support while families are in the NICU. Palliative care teams and ethics committees may also benefit certain populations within the NICU and ensuring that these services are still provided is important.

Table 2 Recommendations for improving parental support in the NICUa.
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For institutions that severely limited visitation of parents to the NICU, a central tenet of modern neonatology was unable to be performed by the parents. Kangaroo Care has been a part of neonatology since 1978 [42]. Countless neonates have benefitted from Kangaroo Care with benefits including; improved temperature regulation, improved sleep-wake cycles, and augmented growth [43]. To deny parents the experience to provide kangaroo care and neonates the demonstrated ability to reap its benefits seems imprudent, especially when, if available, PPE could mitigate unwanted effects of a viral agent. Other ways that families can impact the care when they are visiting include reading to their infants. Several studies have demonstrated improved parental bonding and decreased severity of postpartum depression after reading to their baby [44,45,46]. Parent talk has also been demonstrated to be the strongest predictor of preterm infant vocalizations at 32 and 36 weeks’ gestation [47]. It was noted that infants were exposed to more conversational language when parents were present than when parents were absent [47].

Supporting infants in the NICU

The impact on reduced visitation does not simply affect the visitor, but also has profound impact on the patient as well. The neurobehavioral impact of parental visitation on infants is undeniable [48, 49]. So, in time of reduced visitation, the NICU team needs to ensure that care typically provided by parents does not stop. Talking in conversations to the infant, holding and interacting all can have significant impact over time. Music therapy has been shown to reduce infant respiratory rates and may have other physiological benefits [50]. Ensuring that therapy services such as occupational, speech, and physical therapists continue to help provide developmental support is imperative during this time.

In conclusion, although there is substantial evidence that would suggest parental visitation should not change in the NICU environment, we understand that hospital and infectious disease policies may supersede unit guidelines in the attempt to mitigate viral spread. If parental visitation is restricted, there are mechanisms that NICUs can utilize to ensure that families and infants continue to be supported both in the hospital and when they are away from the hospital.