The Collateral Impact of COVID-19 Emergency on Neonatal Intensive Care Units and Family-Centered Care: Challenges and Opportunities

Abstract

The ongoing Coronavirus disease 2019 (COVID-19) pandemic is disrupting most specialized healthcare services worldwide, including those for high-risk newborns and their families. Due to the risk of contagion, critically ill infants, relatives and professionals attending neonatal intensive care units (NICUs) are undergoing a profound remodeling of the organization and quality of care. In particular, mitigation strategies adopted to combat the COVID-19 pandemic may hinder the implementation of family-centered care within the NICU. This may put newborns at risk for several adverse effects, e.g., less weight gain, more nosocomial infections, increased length of NICU stay as well as long-term worse cognitive, emotional, and social development. This article aims to contribute to deepening the knowledge on the psychological impact of COVID-19 on parents and NICU staff members based on empirical data from the literature. We also provided evidence-based indications on how to safely empower families and support NICU staff facing such a threatening emergency, while preserving the crucial role of family-centered developmental care practices.

Full text

PERSPECTIVE
published: 24 February 2021
doi: 10.3389/fpsyg.2021.630594
Frontiers in Psychology | www.frontiersin.org 1February 2021 | Volume 12 | Article 630594
Edited by:
Efrat Neter,
Ruppin Academic Center, Israel
Reviewed by:
Mariana Amorim,
University of Porto, Portugal
Pamela A. Geller,
Drexel University, United States
Alison Hartman,
Drexel University, United States,
in collaboration with reviewer PG
*Correspondence:
Alberto Stefana
alberto.stefana@gmail.com
†These authors have contributed
equally to this work
Specialty section:
This article was submitted to
Health Psychology,
a section of the journal
Frontiers in Psychology
Received: 18 November 2020
Accepted: 25 January 2021
Published: 24 February 2021
Citation:
Cena L, Biban P, Janos J, Lavelli M,
Langfus J, Tsai A, Youngstrom EA and
Stefana A (2021) The Collateral
Impact of COVID-19 Emergency on
Neonatal Intensive Care Units and
Family-Centered Care: Challenges
and Opportunities.
Front. Psychol. 12:630594.
doi: 10.3389/fpsyg.2021.630594
The Collateral Impact of COVID-19
Emergency on Neonatal Intensive
Care Units and Family-Centered
Care: Challenges and Opportunities
Loredana Cena 1†, Paolo Biban 2† , Jessica Janos 3, Manuela Lavelli 4, Joshua Langfus 3,
Angelina Tsai 3, Eric A. Youngstrom 3and Alberto Stefana 1
*
1Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy, 2Department of Neonatal and
Pediatric Critical Care, Verona University Hospital, Verona, Italy, 3Department of Psychology and Neuroscience, University of
North Carolina at Chapel Hill, Chapel Hill, NC, United States, 4Department of Human Sciences, University of Verona, Verona,
Italy
The ongoing Coronavirus disease 2019 (COVID-19) pandemic is disrupting most
specialized healthcare services worldwide, including those for high-risk newborns and
their families. Due to the risk of contagion, critically ill infants, relatives and professionals
attending neonatal intensive care units (NICUs) are undergoing a profound remodeling of
the organization and quality of care. In particular, mitigation strategies adopted to combat
the COVID-19 pandemic may hinder the implementation of family-centered care within
the NICU. This may put newborns at risk for several adverse effects, e.g., less weight
gain, more nosocomial infections, increased length of NICU stay as well as long-term
worse cognitive, emotional, and social development. This article aims to contribute to
deepening the knowledge on the psychological impact of COVID-19 on parents and
NICU staff members based on empirical data from the literature. We also provided
evidence-based indications on how to safely empower families and support NICU staff
facing such a threatening emergency, while preserving the crucial role of family-centered
developmental care practices.
Keywords: COVID-19, pre-term infant, neonatal intensive care unit, parents, NICU staff, family-centered care
INTRODUCTION
The ongoing pandemic of Coronavirus disease 2019 (COVID-19) has infected, at the time of
writing this article, tens of millions of people and contributed to over one and a half million deaths
globally (see https://covid19.who.int/). Many governments have imposed regional or national
mobility restriction measures in an effort to inhibit its spread. During this global health emergency,
special attention has been given to the potential impact of both the severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2) and the measures taken to prevent the virus from spreading
to vulnerable populations such as people with serious mental illness (Druss, 2020; Stefana et al.,
2020b) and frontline health workers (Chen Q. et al., 2020; Wang J. et al., 2020). However, another
vulnerable population, those who are treated, visit or work in the orbit of neonatal intensive care
units (NICUs), is receiving less attention than it deserves. Infants who require NICU admission

Cena et al. COVID-19, NICU and Family-Centered Care
are exposed to a range of intrinsic and environmental factors
that can lead, as in the case of pre-term birth, to an increased
risk of neurodevelopmental disorders, psychiatric disorders,
and chronic disorders involving various organ systems, which
can persist from childhood into adulthood or sometimes
first manifest in adolescence or adulthood (Saigal and Doyle,
2008; Crump, 2020). However, NICU infants are not the only
susceptible population. Indeed, NICU staff members and parents
also are vulnerable from a psychological perspective. The NICU
staff members frequently encounter work-related stressors that
make them prone to burnout and mental health problems
(Tawfik et al., 2017; Favrod et al., 2018), whereas parents who
have a child being treated in the NICU (i.e., having a critically
ill infant and being physically separated from her/him) often
perceive this experience as psychologically traumatic (Ionio et al.,
2016; Janvier et al., 2016; Sabnis et al., 2019). These issues are
likely to be exacerbated by the added burden of the ongoing
COVID-19 pandemic, which also hinders the implementation
of family-centered care in the NICU, with several negative
consequences for the infants. This article aims to provide
medical, psychological, and allied health communities with
empirical data from the literature on the impact of the COVID-
19 pandemic on NICUs’ and families. We have also developed
evidence-based recommendations for caring family, infant, and
NICU staff amid such a challenging pandemic.
COVID-19 IN FETUSES AND NEWBORNS
To date, no empirical study has clearly demonstrated the
occurrence of intrauterine infection by vertical transmission of
SARS-CoV-2 from pregnant women to their fetuses (Karimi-
Zarchi et al., 2020; Kimberlin and Stagno, 2020; Schwartz,
2020). However, emerging evidence based on the presence
of SARS-CoV-2 specific IgM antibodies in neonates suggests
that vertical or peripartum transmission from a woman to
her fetus is probable (Shek et al., 2003; Dong L. et al., 2020;
Rodrigues et al., 2020; Zeng H. et al., 2020). These results
are based on small numbers of cases, thus the proportion of
pregnancies affected (which seems to be low; Parazzini et al.,
2020) is yet to be determined, and the short- and long-term
consequences for babies born to mothers with COVID-19 are
still unclear. With regard to COVID-19 post-natal infection in
newborns, some studies report cases of neonatal early-onset
infection confirmed by nasopharyngeal and anal swabs positive
for SARS-CoV-2 assay 36-to-48 h after birth (Wang S. et al.,
2020; Zeng L. et al., 2020). Although the majority of infected
infants aged <1 year at diagnosis are asymptomatic or have
mild-to-moderate symptoms, the prevalence of severe-to-critical
symptoms requiring NICU admission is about 10% (Dong Y.
et al., 2020). Furthermore, although having COVID-19 during
pregnancy may cause some pre-natal problems (Zhu et al., 2020),
including pre-term delivery in about one out of four infected
pregnant women (Rodrigues et al., 2020), it did not considerably
increase the immediate adverse outcome of neonates (Dubey
et al., 2020; Parazzini et al., 2020; Rawat et al., 2020; Yee et al.,
2020).
THE PSYCHOLOGICAL IMPACT OF
COVID-19
Infections, deaths, and uncertainty about the future as well as
the economic and social consequences of essential public health
measures used to contain the spread of the virus (i.e., shelter-
at-home, quarantine, isolation and lockdown) are playing key
roles in the short- and long-term social and psychological impacts
of the COVID-19 pandemic (Osofsky et al., 2020; Provenzi
and Tronick, 2020). Sheltering in place entails the loss of daily
routines and a reduction in social activities and in-person
interactions (which, among other things, provide emotional
support). In other words, the current pandemic is reducing
the quality of individual, family, and social life intrapersonally
and interpersonally. Epidemiological studies of the COVID-19
impacts have shown a high burden of psychological distress
(anxiety, depression, and stress) among uninfected individuals,
particularly among females (Gao et al., 2020; Wang C. et al.,
2020). Furthermore, growing evidence indicates that longer
duration of externally-imposed social isolation and an inadequate
home environment (characterized by small size, low levels of
natural luminosity, or limited possibility of privacy) can lead
to a wide range of adverse psychological effects, including
alienation, diminished self-esteem, helplessness, insomnia, and
panic (Brooks et al., 2020; Pancani et al., 2020; Sim et al., 2020),
in addition to the aforementioned distress. Moreover, anxiety,
anger, and post-traumatic stress disorder can endure for months
to years after the end of such mobility restrictions (Brooks et al.,
2020).
Psychological Impact on Parents (and
Their Infants)
Though COVID-19 seems to be a less severe illness during
pregnancy than previous coronavirus diseases, i.e., Severe Acute
Respiratory Syndrome-related coronavirus (SARS) and Middle
East Respiratory Syndrome-related coronavirus (MERS), it
remains a serious disease as a small number of new mothers
may require critical care. There have been few reported cases
of both mother and infant deaths in association with COVID-
19 (Abou Ghayda et al., 2020; Thornton, 2020), and the factors
determining the neonatal mortality seem to be a consequence
of pre-term birth rather than of infection with SARS-CoV-2
(Hessami et al., 2020). Pregnant women fear that they may
be infected and transmit the harmful infection to their baby,
damaging or causing him/her physical pain, whereas fathers
are primarily (but probably not exclusively; Stefana and Lavelli,
2018) worried about the risks for both their partners and
their babies.
Given the current coronavirus-related restrictions, fathers
often are kept out of the delivery room and/or the obstetrics
and gynecology ward during delivery in an effort to protect
patients and staff from infection (Carroll et al., 2020; Gressier
et al., 2020). Mothers with suspected, probable, or confirmed
COVID-19 who must take care of their infants by themselves
(due to their partners being kept from the ward) must apply
standard precautions (e.g., hand hygiene before and after contact
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Cena et al. COVID-19, NICU and Family-Centered Care
with the baby, use a medical mask when near the baby, and
routine disinfection of surfaces and objects used) to preserve
physical health. Such precautions could be psychologically
demanding and complicate the mother’s relationship with her
baby. The first contacts between mother and newborn are
crucial to start the bonding process (Johnson, 2013; Widström
et al., 2019). Immediate skin-to-skin contact and breastfeeding
within 2 h following delivery make new mothers more sensitive
to the infant’s needs, and the infant’s innate interest toward
social stimuli meets a constellation of species-specific caregiving
bonding-related behaviors such as looking, vocalizing, positive
facial affect and affectionate touch that appear soon after
birth (Feldman and Eidelman, 2007; O’Higgins et al., 2013).
In contrast, post-natal separation disrupts the establishment
of the early parent-infant physiological/emotional connection
(Flacking et al., 2012; Welch and Ludwig, 2017) and leads to
inadequate mother-infant relationships that can result in long-
term negative consequences for the child’s cognitive, socio-
emotional, and physical development, as well as interpersonal
relationships (Johnson, 2013). Adhering to the coronavirus-
related restrictions, despite the World Health Organization
recommendation that “mothers with suspected or confirmed
COVID-19 should not be separated from their infants” (WHO,
2020), means that mothers who are suspected or confirmed
to have an infection but are generally in good health are not
allowed to care for and feed for their babies according to
standard guidelines in some countries and hospitals (WHO,
2002), even when applying necessary precautions for infection
prevention and control (Davanzo et al., 2020; Stuebe, 2020).
Furthermore, in some countries, these mothers are not allowed
skin-to-skin contact in the delivery room or in the ward
(this is a pivotal aspect because the early experience of skin-
to-skin contact can lead to decreased nosocomial infections
and pain perception and to improved breastfeeding, sleeping
patterns and neurodevelopmental outcomes; Holditch-Davis
et al., 2014; Lumbanraja, 2016; Johnston et al., 2017; Casper et al.,
2018; Karimi et al., 2019). These restrictions adversely impact
mothers’ mood, self-esteem, self-confidence, and confidence in
their abilities to care for their infant (Morelius et al., 2005;
Bigelow et al., 2014; Krol and Grossmann, 2018; Pineda et al.,
2018).
This situation is even more complex and critical in the case
of high-risk infants. Even in a non-pandemic period, having a
child admitted to a NICU is a traumatic and stressful experience
for most parents (Stefana and Lavelli, 2016; Sabnis et al., 2019),
mainly because of the unfamiliarity and intimidating intensive
care unit environment, the limited ability to provide care for
their child, and the uncertainties and worries about their child’s
outcomes (Obeidat et al., 2009; Stefana et al., 2018). Parents of
infants hospitalized in a NICU are at high risk for developing
anxiety and depressive symptoms or disorders (Mendelson et al.,
2017). They need and desire comprehensive, timely, and clear
information about their baby as well as emotional support
(Franck and Spencer, 2003). Furthermore, these parents are likely
to develop high levels of stress and feelings of guilt and shame,
e.g., for not being able to provide care for their hospitalized child
in the way they want to or from the sense that they are responsible
for their infant’s pre-term birth (Flacking et al., 2007; Roque
et al., 2017; Stefana et al., under review). During the ongoing
pandemic, infants are admitted in an isolated room of the NICU,
and mothers with suspected or confirmed COVID-19 sometimes
may be totally separated from their child for days or even weeks.
In cases where the other parent is also infected, they cannot visit
the infant until the test results return negative. Furthermore,
in an effort to reduce the risk of SARS-CoV-2 transmission,
many NICUs have reduced parental (especially paternal) and
family visitation privileges (Cavicchiolo et al., 2020a; Murray
and Swanson, 2020) regardless of the other parent’s chance of
being infected. Despite parents’ understanding of the need for
visitation restrictions, they are seriously concerned about their
ability to visit, care for, and bond with their hospitalized infants
(Muniraman et al., 2020).
Forcing a parent to be separated from their newborn child
is a devastating experience that adds much to the distress of
NICU admission (Bembich et al., 2020), and could negatively
impact child development and family well-being in the long
term (Erdei and Liu, 2020). Adverse consequences include
reduced opportunities for breastfeeding and skin-to-skin touch
and holding (Furlow, 2020), delayed and reduced parent–
infant interactions (which play a crucial role in early regulation
of the stress response and provide the foundations for the
development of mutual regulation; Stefana and Lavelli, 2017;
Stefana et al., 2020a; Lavelli et al., under review), reduced
maternal bonding and infant attachment, parental emotional
issues (Franck and Spencer, 2003; Latva et al., 2004; Mäkelä et al.,
2018), later parental mental well-being (Lean et al., 2018), and
worse infant/child developmental outcomes (Turpin et al., 2019;
Cheong et al., 2020). For these reasons, the United States Centers
for Disease Control and Prevention (2020) suggest that “the risks
and benefits of temporary separation should be discussed by the
healthcare team.”
Likely, the adverse effects experienced by parents following
their infant’s admission to the NICU are more severe and long-
lasting during the COVID-19 crisis because many traumatic
experiences could have a cumulative effect (Khan, 1963; Sacchi
et al., 2020). A recent systematic review and meta-analysis,
aimed to estimate the effect of the COVID-19 pandemic
on both pregnant and post-partum women’s mental health,
found that pregnant women and new mothers of full-term
and healthy infants report substantially higher levels of anxiety
and depression symptoms compared to similar pre-pandemic
cohorts (Yan et al., 2020). More specifically, the authors found
that the prevalence rates of anxiety and depression among
pregnant women during the pandemic were, respectively 37
and 31%, whereas the prevalence of post-partum depression
was 22% (the pooled prevalence rate of post-partum anxiety
was not evaluated due to the limited data available). Before
the COVID-19 pandemic, the estimated prevalence of anxiety
symptoms among pregnant women was between 18 and
25% (Dennis et al., 2017; Cena et al., 2020a), while the
pooled prevalence of depression among new mothers was
between 18 and 20% (Woody et al., 2017; Cena et al., 2021).
Furthermore, the levels of anxiety and depression of parents
of children who are not infected but are hospitalized during
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Cena et al. COVID-19, NICU and Family-Centered Care
the COVID-19 pandemic are more serious than that of parents
of children hospitalized during non-pandemic periods (Yuan
et al., 2020). Under such distress, previous evidence suggests
that some of these parents may also develop post-traumatic
stress disorder (Ursano et al., 2009; Cukor et al., 2011).
Finally, reduced maternal and paternal mental health may also
lead to additional risk factors for child neurodevelopmental
disorders (Giallo et al., 2014; Cena et al., 2020b). For example,
two recent systematic reviews found that maternal pre-natal
stress is associated with an increased risk of poor socio-
emotional development (e.g., difficult temperament, behavioral
dysregulation; Madigan et al., 2018) as well as of autism
spectrum disorder and attention-deficit hyperactivity disorder in
the offspring (Manzari et al., 2019). Furthermore, a longitudinal
study involving 3,741 father-child dyads found that fathers’ high
post-natal distress and low parenting self-efficacy were associated
with lower parenting consistency and higher levels of hostile
parenting when offspring were aged 4–5 years, and poorer child
emotional-behavioral outcomes at 8–9 years (Rominov et al.,
2016).
Psychological Impact on NICU Staff
Members
NICU staff members are the key players in the provision of
infant health care and family-centered care. Efforts to maintain
high-quality care can be emotionally demanding, due to factors
such as frequent changes in technology and guidelines as well as
recurrent occupational exposure to the pain and distress of high-
risk neonates and their families; this can negatively impact both
personal and professional well-being and performance (Van Mol
et al., 2015; Weintraub et al., 2016; Tawfik et al., 2017). Thus it is
not surprising that even in normal conditions, burnout (defined
as a state of fatigue, detachment, and cynicism) affects 25–50% of
NICU professionals (Profit et al., 2014; Tawfik et al., 2017; Barr,
2020).
The ongoing global health emergency is a stressful situation
for NICU staff both personally as people and professionally as
clinicians. Pandemic-related factors such as (i) over-work or
work with long shifts, (ii) wearing additional personal protective
equipment, which has been described as necessary but time-
consuming and disruptive to clear communication with parents
(Semaan et al., 2020; Cena et al., under review), (iii) being unable
to act according to their own values, the values of the patient’s
family, or the values of the family-centered care model (i.e.,
because of pandemic-related policies enforcing social distancing
and other measures that are not typical in NICU patient care),
(iv) difficulties in meeting the emotional needs of hospitalized
infants and their families while also safeguarding their own
health, (v) anxiety and fear about their personal physical safety
(Chang et al., 2020) as well as that of friends and family members
(whom they could infect while asymptomatic), (vi) emotional
pain for the loss of infected friends/relatives/colleagues, and (vii)
restrictions on personal and social activities are contributing to
increased psychological stress in these people. It follows that these
professionals are at higher than average risk for burnout (Profit
et al., 2014; Crowe et al., 2020), a condition that poses additional
challenges for family-centered care. Thus, NICU staff members
are in a continuously stressful situation both in the workplace and
in their personal lives.
SUPPORTING PERSONS AND
STRENGTHENING NICUS
Next we offer suggestions on how to support and empower both
NICU parents and staff, and strengthen NICU systems, while
emphasizing the role of Family-Centered Care in the NICU
during the COVID-19.
Family-Centered Care
Family-centered care in the NICU requires as primary
components the family’s presence in the ward, family
support, communication with family members, use of specific
consultations and NICU team members, and operational and
environmental issues (Davidson et al., 2017). Despite the fact
that family-centered care is challenged by the current COVID-19
pandemic, leading to visitation restrictions and indications for
physical distancing, its goals must remain the same, though
adapted to and focused on maintaining family integrity and
respecting the role of family members as care partners with
whom to collaborate (Papadimos et al., 2018; Hart et al., 2020).
Given that several important practices in typical family-centered
care may not be feasible in times of pandemic, family-centered
care in the NICU must undergo specific adaptations in order
to be accomplished in the midst of the COVID-19 pandemic
(see Table 1).
Supporting Parents
When parents’ visitation is limited or denied, communication
between them and the NICU team should include a video
component. Real-time videoconferencing is a means for parents
to communicate (and collaborate) with NICU staff and to see
their infant (Lindberg et al., 2009; Gund et al., 2013; Epstein
et al., 2015; Joshi et al., 2016). It is essential in the current health
emergency that parents can see their baby via video when they
cannot be or stay with them in the NICU (Epstein et al., 2017), as
viewing their newborn on a camera reduces parental stress and
anxiety (Rhoads et al., 2015a,b).
A further consequence of visitation restrictions and rules for
social distancing is the loss of in-person, peer-to-peer support
for NICU parents (Hall et al., 2015). Support groups have a
beneficial, normalizing effect on the parental role, emotions,
control, trust, coping, and adaptation to parenthood reality
(Dahan et al., 2020). More generally, offering peer support
is recommended as an integral and crucial component of
family-centered care and comprehensive family support (Hall
et al., 2015, 2016). Although meeting in-person appears to be
preferable, both individual and group peer support interventions
offered by telephone or via the internet appear to be beneficial
(Hall et al., 2015) when the communications are managed by
the same staff who would normally deliver that information
personally inside the NICU (i.e., when not managed by a
“stranger”). Thus, the best solution in the time of COVID-
19 seems to be providing peer support by video and voice
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Cena et al. COVID-19, NICU and Family-Centered Care
TABLE 1 | NICU family-centered care in pre-COVID-19 and COVID-19 pandemic.
NICU family-centered care concept Pre-COVID-19
pandemic
COVID-19
pandemic
Communication
Face-to-face, in-person communication +–
Structured communication +–
Telephone calls + +
Video calls + +
Family support
Peer-to-peer support +(–)
Family education programs (e.g., leaflets,
videos)
+ +
Patient-diaries by NICU-staff +–
Family-authored diaries + +
Family presence
Open or flexible presence at the bedside +–
Participating in team rounds +–
Special consultations
Clinical psychologists or psychotherapists +(–)
Family care specialists +(–)
Family navigators (e.g., care coordinator
or communication facilitator)
+(–)
Spiritual advisor or chaplain’s support +(–)
Table adapted from Zante et al. (2020).
+concept widely applicable, – concept challenging to apply, (–) concept that could be
technically adapted (e.g., through telephone or video calls).
calls. NICUs should develop or implement internet-based peer
support programs, and offer a comprehensive training program
to both veteran parents (i.e., parents who have had previous
experience with their own infant in a NICU, have participated
in the family-integrated care program, and now provide peer-
to-peer support) and NICU staff members who facilitate
the support.
In order to ensure that support by mental health
professionals continues to function, perinatal psychiatric
and psychological services should be implemented
through telepsychiatry (see www.psychiatry.org/
psychiatrists/practice/telepsychiatry) and telepsychology
(see www.apa.org/practice/guidelines/telepsychology
and https://w.wiki/NYz) (Hermann et al., 2020; Perrin
et al., 2020; Zork et al., 2020). This might include the
development of telephone helplines manned by mental health
specialists, specifically addressing the needs of parents with
hospitalized infants.
Finally, it is crucial that when parents are allowed to
visit in the NICU, the healthcare team put in place all
the interdisciplinary recommendations for educational and
emotional support (Hynan et al., 2015) and for encouraging
and involving them in the care of their baby (Craig et al.,
2015). Regarding emotional support, the implementation of
evidence-based assessment (EBA) and treatment appear to be
essential to reduce parents’ burden at individual and public
health levels. An EBA model that could be usefully adopted by
NICU mental health professionals is that devised by Youngstrom
and colleagues (Youngstrom, 2013, 2014; Youngstrom et al.,
2015, 2017, 2018; Youngstrom and Van Meter, 2016, 2018;
Youngstrom and Prinstein, 2020). This EBA 2.0 model (see
Table 2) combines empirical research and pragmatism of
application to identify the most appropriate measurements
and sequence their order to minimize redundancy and
unnecessary testing. Such an effective and efficient assessment
process is crucial because it leads to more accurate diagnosis,
appropriate intervention, better treatment matching, and
enhanced outcomes.
Supporting and Empowering NICU Staffs
From the above, it follows that it is vital to adequately support
NICU staff members in maintaining their security and safety
(e.g., personal protective equipment to protect themselves) and,
more generally, that hospital institutions make them feel cared
for. At the same time, being on the front line to cure and
care for the most vulnerable (especially newborns and their
families) and being a member of a highly specialized team who
bravely faces this threat while continuing to do their jobs are
elements that can encourage and even make healthcare providers
fittingly proud of themselves and their efforts (Barello et al.,
2020a,b). In addition to the above responsibilities, usually NICU
staff are also the primary point of contact with the general
health system for the parents of hospitalized infants, and as
such could (and should) also be the first observer/responder
for both SARS-CoV-2 and mental health conditions for many
of these parents. Thus, NICU staff need specific training to
recognize the signs and symptoms of both COVID-19 and
the most common post-partum mental disorders (i.e., anxiety,
depression, and psychological distress). Additionally, in this
scenario, NICU staff would ideally have (i) accurate and clear
guidelines, (ii) access to online screening tools to explore their
own mental health status and determine whether they should
contact a mental health professional (e.g., www.hgaps.org/as
sessment-center.html and www.dbsalliance.org/education/ment
al-health-screening-center/), (iii) the provision of a dedicated
psychological help service for healthcare professionals located
in the hospital or through a telephone helpline staffed by
mental health professionals not affiliated with the NICU, (iv)
training on COVID-19 management, (v) training on the use
of mobile and web technologies needed to provide support at
a distance to parents, (vi) training and access to brief anxiety
and depression scales to use for monitoring families’ distress
(e.g., www.hgaps.org/assessment-center.html and www.dbsalli
ance.org/education/mental-health-screening-center/), and (vii)
a forum for discussion, advice and support from colleagues.
These support and training measures are essential and must be
developed and implemented, particularly if the pandemic and
its aftermath will continue for a long time. If professionals do
not have accessible resources and support to take care of their
physical and mental health, they will not be able to deliver the
appropriate care and critical services to the most vulnerable
populations, including infants and NICU families, during
this pandemic.
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Cena et al. COVID-19, NICU and Family-Centered Care
TABLE 2 | Strategies for adding Evidence-Based Assessment techniques for mental health issues to the NICU (adapted from Youngstrom et al., 2017).
Assessment step Suggestions for doing in NICU
Preparatory work before seeing patient
A. Plan for most common issues Have screening tools and tip sheets for anxiety, depression, acute and post traumatic stress disorders (both
parent- and staff-facing); burnout
B. Benchmark base rates for issues Benchmark local rates against prior years, regional and national data, and/or published estimates
Admission (“Prediction phase”)
C. Evaluate risk and protective factors Make short checklist of key risk, protective factors to improve consistency and coverage
D. Revise probabilities based on intake assessments Have cheat sheet with updated probabilities based on screening results and suggested language for follow-up
(Well-supported staff could use free online calculators, nomograms, more traditional Evidence-Based Medicine.)
E. Gather collateral, cross-informant perspectives Assess both parents and relatives (e.g., grandparents) when possible, and share psychoeducational resources
(infographics, tip sheets, online tools). Regarding staff members, information should be collected also from NICU
colleagues and managed by mental health professional not affiliated with the NICU.
Targeted follow-up (“Prescription phase”)
F. Add focused, incremental assessments If using ultra-brief screeners, have full-length assessments ready for follow-up. Family can do quickly while on unit,
or from home. Often same tool can used as Patient Reported Outcome (PRO).
G. Brief structured interviews Have short, structured interviews for common mental health issues (e.g., PRIME-MD, DIAMOND) and orient staff to
using anxiety, mood, trauma modules.
H. Case re-formulation and goal-setting If findings suggest mental health issue, provide referral options, psychoeducational resources.
X. Learn and use client preferences Discuss options and risks and benefits; address common concerns or misconceptions, problem solve around
barriers
Monitoring throughout the infant’s stay in the NICU and after discharge (“Process Phase”)
I. Goal setting: Milestones and outcomes Have “cheat sheet” with benchmarks for Minimally Important Difference (MID), clinically significant worsening or
improvement on PRO (Step F)
J. Progress tracking Can repeat PRO (Step F) weekly while in the NICU and at each follow-up visit after infant’s discharge.
K. Maintaining gains Celebrates gains; and plan for continuity of care and ongoing support for family. Develop list of key indicators,
recommendations about next action if starting to worsen.
CC BY 4.0 Eric Youngstrom, PhD.
See https://en.wikiversity.org/wiki/Evidence- based_assessment/NICU for links to tools.
Strengthening NICU Systems
The COVID-19 global health crisis is a disaster; however, it
can also be an opportunity (Stefana et al., 2020c; Youngstrom
et al., 2020) to improve health care systems and services by
including an increased number of NICU staff members, adequate
resources and training, and improved visitation policies for
family members of hospitalized infants. Before the COVID-19
pandemic, there was a widespread and substantial shortage of
NICU medical and nursing staff (Rogowski et al., 2013; Gagliardi
et al., 2016; Bliss, 2017) the current crisis has highlighted. Indeed,
three of ten NICUs were already understaffed compared to
national guidelines (Rogowski et al., 2013). This is particularly
important in pandemic times because understaffing is associated
with children’s adverse outcomes, including a heightened
risk of nosocomial infection on very-low-birth-weight infants
(Rogowski et al., 2013). Despite understaffing being a significant
risk factor for poor patient outcomes, it is infrequently addressed
by interventions (Stapleton et al., 2016).
In many cases, the needed restrictions and containment
measures (Cavicchiolo et al., 2020a,b; De Rose et al., 2020)
that are in place to deal with the COVID-19 emergency are
exacerbating the problems associated with meager adoption of
family-centered care principles in NICUs. During these months,
it has been common to hear colleagues say that “COVID has
made us go back decades in the quality of family support we
provide.” This is a serious negative development because care
should be all the more humane and person-centered during
the COVID-19 pandemic; a goal that becomes fully achievable
only through a strengthened involvement of patients’ families
(Coulter and Richards, 2020) and the support and empowerment
of frontline healthcare workers. The development of online
support groups, video and messaging platforms to increase
communication between families and providers, as well as peer
support, all are innovations that should continue even after
the pandemic ends. As such, the present healthcare crisis can
increase the awareness of healthcare specialists about the critical
need to enable open access of families to the intensive care unit
environment, and an active engagement of parents in the primary
care of hospitalized newborns and infants at risk. The tools and
techniques developed in response to the disruption of the system
can ratchet practice forward.
CONCLUSIONS
The COVID-19 pandemic has dramatically changed the lifestyle
of people worldwide, while disrupting healthcare services and
systems, including NICUs. The mitigation strategies adopted
to manage the pandemic have upset care delivery for high-
risk newborns and their families, and the mental health legacy
of the pandemic will likely endure – for both NICU staff
Frontiers in Psychology | www.frontiersin.org 6February 2021 | Volume 12 | Article 630594

Cena et al. COVID-19, NICU and Family-Centered Care
and family members – long after the acute phase (Erdei and
Liu, 2020; Lemmon et al., 2020). It is vital to deepen the
understanding of how the pandemic has influenced family-
centered care practices and dynamics in NICUs, gauging the
psychological impact of COVID-19 on parents and frontline
professionals. This article provides evidence-based strategies
to aid NICU staff members engaged in ensuring high-quality
care and supporting critically ill newborns and their families
(Tscherning et al., 2020). We proposed several ways to safely
support and empower NICU staff and enhance family-centered
developmental care practices, without increasing the risk of
contagion. Apart from evidence-based training on cutting-edge
COVID-19 management tools, high priority should be given to
the preservation of family-centered care principles, including
parents’ presence in the NICU, parent-infant physical and
emotional closeness, and parental involvement in the infant’s
care. Furthermore, NICU systems should implement evidence-
based assessment and treatment for parental distress while
providing peer support for parents by video and voice calls.
Finally, NICU systems should ensure dedicated psychological
help services for healthcare professionals, being particularly
exposed to a higher risk of burnout COVID-19 related.
AUTHOR CONTRIBUTIONS
AS designed the study. AS, EAY, PB, JJ, ML, JL, AT, and LC
contributed to the manuscript writing. All authors contributed
to the article and approved the submitted version.
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Conflict of Interest: The authors declare that the research was conducted in the
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