Family centered care. KMC for small and sick newborn by Prof Angela Anene Okolo

The functional unit of care for the child is the family. The mother is key to child life and childcare in health and in disease. It is very difficult for the young child to understand and accept separation from the mother when he is sick. In the context of our cultural setting in Africa: when any family member is sick, the entire family is sick. When the child is sick, the entire family especially the mother is distraught. Therefore, it had been that when a child is admitted to the hospital the mother moves to the hospital with her mat to sleep by the child’s bedside if allowed or else she sleeps along the corridors of the ward! No matter what the health providers do to keep her away from the wards because of the health workers perception that her presence “disturbed the implementation of the ward routines” because she made the place untidy! I examined this subject and applied a basic principle of child health. This supports the idea that hospitalization of the child should not only serve as a point of contact for treatment but also as a point for teaching and learning best practices for child health promotion. Therefore, it is an opportunity to strengthen health education on a targeted subject area as well as general health promotion.

The Practice and Method utilized What do we do in our setting?

Various aspects are operated both for the older child and for the newborn. The issue of focus here is the application to newborn care.

Practice in the Newborn Neonatal Unit (NNU): The Setting

Essentially, babies in our Newborn Neonatal Unit (NNU) Settings at FMC, Asaba come with their mother and or care giver. There is a mothers’ room within the unit equipped with its toilet amenities, bed and lockers and fridge. Since there is, a 10-bedded facility for inborn babies and a 10-bedded facility for the out born newborns each of these areas are equipped with their mothers’ room area in the unit. Within this mothers ‘ward, there is a dedicated area for Continuous Kangaroo mother care [KMC]. There is a centrally located Television in the ward, which serves dual purpose, for both parental education and recreational viewing. Within the central lobby area, there is a demarcated area for the preterm follow up upon discharge. In this location, babies of less than 2500 grams are seen biweekly until they attain the weight of 2500 grams when they are seen at the neonatal outpatient clinic.

In the newborn ward itself, within each babies’ space, there is a chair for the mother to sit and practice intermittent kangaroo mother care and she can also express breast milk as she cares for her baby. It is a compact space that allows for just herself and her baby’s needs. We practice Feeding with Mothers breast milk or Donor Milk, KMC and mother’s participation in care of the baby to the extent the state of the baby allows and so continuous presence of all the mothers of babies is encouraged. Fathers are allowed to visit when the need arises outside the visiting hours. When the mother cannot be present from the time the baby is admitted because of maternal illness, we request for the presence of a caregiver to facilitate constant contact with the family.

The term family-centered care recognizes the family as a constant in the child’s life and therefore in practice it attempts to Facilitate parent-professional collaboration at all levels of healthcare. This actually responds to the reality of life. Attempts to admit newborns and provide very good care, from observation and experience is seemingly futile effort as mothers are sitting or lying outside on the corridors of the SCBU unit under very hard conditions in anxiety for what may be happening to their child. Whereas implementation of Family Centered care, (FCC) affords the opportunity for building stronger relationships between provider, family and patient. Parents are given opportunity to participate in the development of a proper treatment plan. This enables the development of better approaches to treatment that is adapted to the individual child’s needs.
By implementation of this approach, health providers respect the unique contribution family members make in promoting a healing environment for the child. This approach promotes open communication with the parents and providers. This is a key opportunity for health care promotion. Open communication during pediatric care helps foster a stronger relationship between the provider, family members and the patient.

Collaboration between Key Family Members and Health Providers: Family-centered pediatric care goes beyond just communicating openly. It also involves parents in the development of a proper treatment plan. With the valuable input of family members, health providers are most often able to develop better approaches to treatment that serves specific needs of the child. A key example is the development of a feeding plan for the sick and small newborn. We take into cognizance what the nurses and the mother tell us about the tolerance of feeding regimen for the baby. “To feed 2 hourly or 3 hourly” depends on the considerations and parental inputs. Who feeds the baby? The feeding practice of the sick and small newborn transits from gavage tube feeding by the health worker to cup feeding by the mother under supervision. This way the task of feeding eventually shifts to the mother. This practice fosters the principle of Enabling

Family support during Treatment. Even the practice of giving the newborn a bath is along these lines. This allows the parents to a reasonable extent to implement certain aspects of care, other aspects that I would term medicalized care the mother observes what the ideal practice should be. For example, “cord care for the baby whilst still in hospital”. Family involvement and participation is an important factor in promoting the well – being of the child.

Family centered care does it work?
In the context of this concept, we observe that certain areas could be cause for constrains if not properly addressed. Such areas provide the loophole for more negative findings than positive, with barriers to parental involvement, problems with communication between parents and health staff and difficulties with role negotiation for parents and those caring for the child. Health staff may think that parental presence may pose a threat to care of the baby. On the other hand, parental presence should not replace the need for care to be provided by the health care staff. Although difficult to study because it evolved from the works of several organisations interested in the welfare of children in the 1950s, it is current practice in vogue!. The reality is that it is difficult to implement because of the suggested misconceptions of the health workers. It is a wonderful ideal, but very difficult to implement effectively because of the tensions in communication that seem to be an inevitable occurrence in parent – health professional interactions. If the family is well prepared and the health workers imbibe the concept, areas of conflicts will be minimized.

These definitions are important, but we are still left with the question – yes, but what is it?
Why is it so difficult to implement and measure? We need to think about what family-centred care means for those for whom it is designed – children and their parents and the staff who care for them. If the family is the central tenet in the child’s life, then health services need to make provision for them. In the true sense of the practice, Structural aspects should be addressed. Beds would be needed for parents who want to stay alongside with their children. Provision should be made for the parent’s conveniences.

Places to eat and cheap and nutritious food would be required. Parents staying with children often find themselves financially compromised, having to pay for expensive food. In our setting, we had negotiated provision of food to the mothers at subsidized rates but mothers preferred to buy their food from the food vendors in the environment rather than the subsidized hospital provided meals after a brief period of trial. For the older child outside the neonatal period, School and play facilities are needed and television and computer games (for both child and parent). For the preterm in the newborn unit, fancy colored toys and music making devices individualized for the baby is needed for environmental stimulation.

Once the structures are in place, then education needs to be considered. All the health service staff – not just the health professionals – need education about what family-centered care entails. So do parents and children, as there is little point in educating the health service staff but not ensuring that the expectations of children and parents are aligned with the expectations of those delivering care. Attention is equally given to this aspect.

The education is quite relevant, as the health care staff and the parents are educated on the essence of this type of care. We listen and learn from them what the expectations are. Targeted aspects of health education are also addressed. This is in essence how we involve them in the care of the children in our practice. We teach the mothers how to ensure safe feeding for the baby through cup feeding and they know that they have to demonstrate mastery of these skills before discharge. We teach them about the importance of thermal care for the small baby as she provides this through KMC. We teach the need for the practice of kangaroo KMC. KMC not only meets the thermal needs but also covers the nurturing aspects as this meets their psychosocial needs to bond with the baby.

Effective Communication is requisite in the practice of Family centered care
Thus in practice, we communicate with the mothers of babies during admission and before home discharge. We tell them what we expect of them that would help to promote the babies well-being. We communicate both at group level and at individual level. We demonstrate to them the essence of a) KMC particularly the rationale behind the practice of continuous KMC for the growth and well-being of the small baby. We teach them the need to observe strict hygiene to protect the baby from infection such as hand washing and hand sanitizing and upon home discharge, the need to keep the baby away from visitors until the baby achieves the weight of 2500 grams or 40 weeks post conceptual age. We also discuss the need for follow up of these babies at the preterm or neonatal follow up clinic.

True family centered care does not necessarily mean that the parent must be hospitalized with their child, the health staff must also be interested in what is happening to the rest of the family at home. True family-centered care means in-depth exploration of family situations and negotiation to determine the “best fit” for care of the admitted child. Hence, often times in our practice, we ask the family to provide a helper to assist and share the support with the family as would be needed. FCC does not necessarily mean that less number of staff should be on duty. The requisite number of nursing staff would still be required to Mann the ward because FCC implies close monitoring supervision of the caregiver to inform the objective counselling. It implies empathy, negotiation and consideration of what augurs best for the interest of the child. Hence, sometimes to promote parental care and participation in the provision of KMC, we allow the father to give KMC so that upon home discharge, the mother can rest while the father provides the KMC.

Discussion and Conclusion
We do not have a uniformly representative model in our setting but we can use the too well know term of Family-centered care(FCC) because we implement some of its elements given that we have in place some of the tennets of the FCC in practice within our nursery.
Even if what we practice may not be the model, it implements the concept. In essence, we try to bring the family to the realization that they own the baby and we are just enablers for both the curative aspect and health promotion aspects of care.
This concept is yet to gain grounds in our setting. There are current myths and controversies around the subject of FCC in our environment. Adoption of this practice that was partially existing in middle low income (MICS) settings where health facility utilization for maternal newborn and child health (MNCH) care is still low, may foster and strengthen health messages and enhance community participation in care and health seeking behavioral change.

To make FCC work in our setting, commitment by leaders of all health professions and managers of health services is needed. This requires education and lobbying and, importantly, discussions with policy makers such as ministers for health and social care and executive level directors. Essentially, though, it needs the commitment of those who will use it – the health professionals, health service staff, children, young people and parents for whom it is designed should play a major role in the promotion of this concept. It is indeed crucial for effective implementation of the Kangaroo mother care.
The implementation of FCC, also allows us to cater for the psychological support of the mothers of sick and small preterm newborns who are often times emotionally distressed. In fact, in our setting in at FMC, Asaba, the clinical psychologist works very closely with us and she supports these mothers psychologically as they go through the stress of caring and supporting their very small sick newborn babies.

In conclusion
Family centered care should be promoted as the way forward for care of the very small and sick preterm newborns to foster KMC. It enhances the medical care provided to these babies and promotes their psychosocial wellbeing. It fosters the provision of KMC and other forms of care provided to these babies. We have observed shorter duration of hospital stay in babies commenced early on intermittent KMC between the use of incubator care and babies who solely had incubator care. We need more work in these areas.


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