While 2020 is now behind us, we are still reeling from the uncertainty and stress that has accompanied the COVID-19 pandemic. Current recommendations for neonatal care in the context of COVID-19 call for testing, handwashing/hand sanitization, wearing of personal protective equipment, social distancing, quarantining to reduce exposure, and isolation if experiencing symptoms.1 Moreover, great advances have been made in the prevention and spread of the virus; however, emerging literature highlights the deleterious effects of well-intentioned hospital-based policies for the care of infants and families in the neonatal intensive care unit (NICU).1 The lack of evidence about the novel virus has caused a steep learning curve among professionals and the public.

Practices aimed at protecting healthcare staff and patients from exposure and spread have also heightened confusion and fear, decreased facial recognition, muffled communication, and limited parent/family presence at the bedside.2 These practices are linked to depression, anxiety, and isolation for parents in the NICU.2 Healthcare providers share concerns regarding the potential risks of long-term mental health outcomes for infants and their parents.1 These stressors may influence our ability as providers to support infant-parent regulation and relationships.

Over the last 50 years, the focus of neonatal care has been on the biophysiological management of premature and sick infants, with care occurring within a rapidly changing technical environment. However, understanding the holistic needs of the infant as a biophysical-psychosocial-emotional interactive complex system within a nurturing parent/family relationship is central to the infant's optimal health over the life span.2,3 A greater emphasis on infant- and family-centered developmental care (IFCDC) principles and infant mental health (IMH) is foundational to guide interprofessionals in supporting the healing, growth, and development of the infant in an intensive care environment.3

The IMH emerging science emphasizes the importance of safely engaging the family in the care, culture, and environment of the infant to promote internal regulation, coregulation between the parents, social-emotional development, and positive mental health.1,3 IMH principles include understanding growth and development in the context of the infant's environment, consideration for the individual developmental needs and perspectives of the infant, and reflection on ways the NICU affects the infant's development and relationships.3 Integrating IMH principles in the healthcare culture, policies, and procedures of practice can make a difference in the short- and long-term outcomes of the infant, parent(s), and family.3 It is important now more than ever to support IMH in the NICU during the COVID-19 pandemic.

An interprofessional Consensus Committee consisting of nursing, neonatology, physical and occupational therapy, psychology, social work, speech-language, and parent support professionals developed 6 domains of IFCDC, which are described through standards, and competencies of best practice.4 These domains include the following:

1. Systems thinking in complex adaptive systems;

2. Positioning and touch for the newborn;

3. Sleep and arousal interventions for the newborn;

4. Skin-to-skin contact with intimate family members;

5. Reducing and managing pain and stress in newborns and families; and

6. Management of feeding, eating, and nutrition delivery.

In an effort to support infants and families through the pandemic crisis, the IFCDC domains highlight areas in which nurses can advocate and support policy changes that promote IMH in the NICU. Policies that center the family in the care of the infant are "essential."5 Parent education regarding infant care and infection prevention/control should occur at the bedside.2 Virtual, video, and audio electronic measures can be used to promote communication and enhancement of parent engagement when parents are unable to visit.1 Parents should also be involved in the scheduling of rounds for shared decision-making with the healthcare team, collaborating in developing the plan of care.2

Healthcare providers can also teach parents the techniques of touch, handling, positioning, holding, and transfer to/from the bed with medical devices to support their infant's development. Assessing and evaluating the well-being of parents in the NICU are best performed in a timely and appropriate manner-during the time of stress, not delayed or optional.1 Identifying the proximal and distal stressors affecting each infant, parent, and family can help individualize support and self-care strategies to cope.3 Nurses are well positioned to offer both behavioral and environmental recommendations to support the well-being of infants and families.

Provision of IFCDC care and IMH is essential to the health of infants, parent(s), and families, especially during critical times such as a pandemic. Integrating the 6 domains of IFCDC into nursing care may help ensure that IMH needs are met in the time of COVID-19 and thereafter. In our efforts, we should aim to create more flexibility and support using evidence-based approaches that promote IMH principles. Strategies to secure the presence of the parent with the infant are critical, and nurses are in the unique position to advocate for policies and procedures that enable this type of support. While many changes may be made in response to COVID-19, we hope that you will consider maintaining these recommendations beyond the pandemic. See https://nicudesign.nd.edu/nicu-care-standards.

Sincerely,

-Kelly McGlothen-Bell, PhD, RN, IBCLC

-Joy V. Browne, PhD, PCNS, IMH-E (IV)

-Carol B. Jaeger, DNP, RN, NNP-BC

-Carole Kenner, PhD, RN, FAAN, FNAP, ANEF

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