Stephanie Dewes and Stefan Shearer arrived at Oregon Health & Science University’s emergency department in January with a life-threatening prenatal diagnosis: A placental abruption — the placenta detaching from the uterus wall — that required an emergency Cesarean section.
After the surgery, their care team suspected that their new baby, Clara, had suffered a brain injury due to the sudden lack of oxygen; she was immediately taken to the OHSU Doernbecher’s Neonatal Intensive Care Unit to begin treatment.
In most NICUs, Stephanie and Stefan wouldn’t be able to hold Clara for several days as she underwent treatment. But at OHSU Doernbecher, a unique program created through a collaboration among programs and care teams allows parents to hold their NICU babies as soon as possible, ensuring the infant and parents are able to experience key bonding moments in the first few days of life.
“Everyone was so supportive. It made the whole process seem a lot less scary knowing that holding her was a possibility and that the providers felt confident about it being safe,” Stefan said. “That moment was incredibly impactful in our transition to becoming parents.”
For infants like Clara who are born with neonatal encephalopathy, a neurological condition in newborns that can lead to respiratory problems and seizures, the moments after birth include a swift transfer to the NICU for treatment.
The treatment is therapeutic hypothermia, which lowers body temperature to minimize neonatal brain injury. By cooling the newborn’s head or whole body, the cellular metabolism is slowed, which reduces inflammation and allows brain cells to recover from injury. To be most effective, the treatment must be started within hours of birth and continue for three days without interruption, impeding parents’ ability to physically bond with their child.
Parental holding not only provides a valuable bonding experience for families, but also supports infant brain development and reduces stress, said Emily Garavatti, M.D., a resident in OHSU’s pediatric neurodevelopmental disabilities program.
However, facilitating parental holding for infants in the NICU can be challenging, and even dangerous, without evidence-based protocol and meticulous planning. The complex care provided in the NICU requires life-saving physical equipment, such as breathing tubes or umbilical lines to receive nutrition and medication, so parents typically cannot hold their child until after treatment is completed on day four of life.
Safety, efficacy, bonding
Understanding the benefits of parental holding, Garavatti and Taralyn Calder, RN, a neonatal nurse, were determined to find a new care process that would better serve these young patients and their families.
“From a developmental standpoint, infants are missing out on key bonding moments, and on top of that, parents are scared to interact with their own child,” Garavatti said. “When you have a child in the NICU, you just want to feel some sense of normalcy and be assured that everything is going to be okay — physically holding your child can be a big part of that.”
There is no uniform approach or official clinical recommendation that parental holding be offered during therapeutic hypothermia, and very few facilities nationally offer this option; Garavatti and Calder developed OHSU’s process from the ground up.
The first step was developing a survey to gauge NICU staff’s comfort level with parental holding and gather feedback and clinical data to maximize safety and efficiency. A similar survey was also distributed to neonatal providers across the country to gain a better understanding of this care in practice.
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Developing a clinical framework for parental holding required collaboration among pediatric neurology, neonatology and NICU nursing staff to establish comprehensive, evidence-based care guidelines. It also entailed developing a quality improvement database to collect information on safety and efficacy. Most importantly, Garavatti and Calder said, it required team-wide commitment, a willingness to learn, and the desire to improve clinical experiences for patients and families.
For Stephanie and Stefan, after the initial fear and uncertainty, the opportunity to safely bond with Clara was priceless.
“By the time we actually got to see her in the NICU, they could have shown us any baby and we wouldn’t have known it was Clara,” Stephanie recalled. “It was all very disorienting. We hadn’t spent any time with her, so didn’t have the ability to form that instant connection.”
Upon arrival to the NICU that evening, their care team told Stephanie and Stefan that they’d be able to transfer Clara to their arms while keeping her safely in the cooling treatment. Stefan and Stephanie were also able to hold her in the following three days of treatment.
Clara is now a happy, healthy four-month-old who has grown and thrived since her stay in the NICU. When reflecting on their birth experience, Stefan and Stephanie say holding their baby was a significant and transformative moment.
Looking forward, providers will continue to track and analyze safety data to inform recommendations for holding, as well as investigate other potential forms of parental involvement. They will also evaluate how to facilitate parental holding for babies receiving other treatments in the NICU, including those that require a special type of ventilator.
“Parents in these situations are scared and unsure of what might happen with their babies, so being able to hold your child feels like a light in an otherwise dark experience,” said Brian Scottoline, M.D., Ph.D., associate professor of pediatrics in the OHSU School of Medicine, who specializes in caring for critically ill infants. “We hope this work can provide an example to other hospitals and make this experience more feasible for parents in similar circumstances.”