The Neonatal Intensive Care Unit (NICU) is not a place most parents expect to find themselves. For parents whose child has a stay in the NICU, whether for a few days, weeks or even months, it is a time of mixed emotion – gratitude for a safe birth and excellent medical care, yet anxiety until the child is discharged.

One in ten pregnancies in the US are pre-term, and driven by a range of factors such as advances in medical care. Of the 3.8 million births each year in the USA, around 150,000 (or one in twenty five births) end up spending some time in a NICU, with significant variation by region and demographic

It is a place where you will meet the kindest, most compassionate and talented medical workers, nurses and hospital staff. As every parent who has had a child in a NICU can tell you, these are individuals who work around the clock and with full dedication to ensure all NICU babies have a brighter future.

However, in the Age of Covid-19, what does it mean to have a child in the NICU?  Here are ten observations:

1. No-one predicted a pregnancy like this

Covid-19 spread internationally barely 6 months ago. Many women who were carrying a pregnancy at that time, could not have anticipated how different their pregnancy would turn out in the midst of a global pandemic.

For example:

  • Taking many additional precautions. With expectant mothers and young babies being particularly immuno-suppressed, many couples would have followed stricter physical distancing measures from friends and family (including virtual Baby Showers), carefully coordinated grocery deliveries, strong disinfecting protocols after each outdoor trip, restrictive exercise given lockdown measures and attempting to juggle face masks whilst pregnant.
  • Less pregnancy preparation. Whilst critical medical care for expectant mothers has not been cancelled in many countries, most pre-natal trips and visits to doctors would have ended up becoming virtual, or having various unusual protocols in place to minimize any spread within such facilities. This means many first-time parents may have missed out on vital pre-natal lessons such as infant CPR, and may feel less prepared for their newborn.
  • Creating a virtual support network. With Covid-19 travel restrictions, many extended family members have not been able to travel long distances to be with expectant parents. So most first-time parents who live away from grandparents and other close family members are likely to have carried the pregnancy and delivery on their own, with minimal in-person guidance. At the same time many grandparents have quickly brushed up on their digital skills to stay in contact with expectant parents and their newborn. Whilst it is not the same as having the reassuring touch of an experienced grandparent nearby, technology used in the right way can be a powerful way to bring families together.

2. The initial shock of a NICU

Most parents did not anticipate being in a NICU. For many, it could have been an unexpected development in the pregnancy that led to an unscheduled or early birth and a surprise stay in the NICU. This can be a shock initially, and a contrast what was expected seeing other friends’ and family’s joyful photos and stories of their newborn children. 

Despite an intimidating set of machinery, after several days families realize that the NICU provides the very best medical care to their newborn. The nurses, doctors and hospital staff in the NICU are among the most talented, working with very fragile young babies, with the most advanced medical equipment. Having a child in the NICU means that a child is receiving the very best medical care, and caring nursing.

Many parents’ posts about the NICU have shared what this experience felt like before the coronavirus pandemic.

3. Making the NICU your second home

Some hospitals used to offer tours of the facilities ahead of birth. With Covid-19, many of these tours have been cancelled or have become virtual. This means the first time that many parents hear of a potential complication and their child is taken to a NICU, this would have been the first time they would have experienced such an environment. 

It takes a few days for many first-time parents to adjust to this new reality, with added disorientation and practical considerations such as the discharge of mothers whilst their child is still in the NICU, location of car parking facilities and food facilities, at a time when many of these services are not operating as normal, and even administrative considerations such as selecting a name for the registration of birth for an unexpectedly early newborn.

4. Strict Covid-19 protocols in the NICU

All NICUs have very stringent Covid-19 protocols. This includes face masks, medical workers washing hands in between each patient, negative pressure rooms for any Covid-19 patients, a stringent visitor policy (often restricted to one parent at a time), regularly Covid-19 testing for all NICU staff and visitors for Covid-19.

This gives reassurance that NICUs are taking the Covid-19 threat seriously, and putting in place appropriate measures.

However, the strict visitation policy has come up in several countries, particularly where mothers are just recovering from a major surgery and a disproportionate burden is placed on them by making mothers the only permitted visitor to a child in the NICU.

5. Keeping ‘the team’ strong

Parents need to take care of themselves, and even more so during Covid-19. The NICU can be a particularly intense experience, even without a global pandemic and economic unrest. Whether it is a first child, first child in NICU, twins, or health complications, every family and child’s story is unique and comes with its own set of challenges and circumstances. It is particularly important that parents are able to take care of themselves during this period. 

Trying to manage hospital visitation logistics, prepare the baby’s feeding and medicine, track a baby’s progress with doctors and nurses, sleep and eat yourself, and spend time with a newborn is an all-consuming experience, exacerbated with Covid-19 restrictions that may hamper access to services once taken for granted.

The challenges of postpartum depression have been sufficiently well reported on, and is an area that NICUs need to be mindful of when setting various support policies for parents.

At the same time, other NICU parents have reported that each child is on their own journey. Whether it is the major health milestones such as overcoming an illness, responding positively to a treatment, breathing independently, regulating critical bodily organs, digesting effectively, feeding through the ‘suck-swallow-breathe’ steps, gaining weight, each child’s journey will be different in pace and sequence based on their particular circumstance.

6. The importance of parent-child bonding amid Covid-19

An important component for a child to be discharged is for that child to meet critical milestones around independent breathing, regulation of vital bodily organs, digesting, feeding. Whilst the medical side is important, several of these milestones are development related, and can be impacted by the newborn feeling loved and relaxed. This has become known as Kangaroo Care.

This is why it continues to be best practice (and World Health Organization guidance) in many NICUs to encourage skin to skin time with parents (who have been cleared for Covid-19) and maintain that parent-child bond.

7. Innovative ways to bridge the distance

For parents who are in the NICU, they may need to find creative ways to bridge the distance with each other and extended families who are unable to travel. Several NICUs are now developing pilot projects around using sound recording devices to help record familiar, extended family voices to play back to the newborn, especially where NICU visitation policies have become more restrictive.

Care must be taken with such equipment, however, to ensure that these do not interfere with the sensitive medical equipment and health of a newborn, i.e., no wifi, bluetooth, minimized use of screen’s blue light, and careful volume control.

8. Meeting other NICU parents

Many NICU parents often ended up bonding for years afterwards, given their experience. For longer-term residents of the NICU, parents may start recognizing the frequent visitors and form bonds with them, celebrating the small wins that are needed on the road to discharge (at whatever stage a newborn is at). Every newborn has their own story and path in the NICU.

With Covid-19, it may be slightly harder to recognize the face of many parents through facemasks, and many NICU reunions have become virtual, but the experiences appear to have kept these family bonds strong.

9. Preparing for discharge from the NICU

There are many outcomes possible in the NICU, depending on each child’s circumstance. For those who are likely to be discharged, there may be particular care needs for a period of time afterwards. This could be a particularly anxious moment for parents, without the broader support networks many had counted on at home given Covid-19.

For example, many premature babies have special care needs for the first few months. For first time parents, without a support network of grandparents and other experienced parents around, this can be particularly disorientating. If the discharge date is upcoming (there’s usually at least a 48 hour notice window to prepare before NICU discharge), it is just as important to have a Discharge Plan prepared and agreed with the NICU. Just as important as the medical discharge formalities, is the social aspects of discharge to ensure you have a home environment prepared to welcome the newborn home.

Many NICUs used to have discharge classes to help prepare parents of NICU babies for post-NICU care at home. With many Covid-19 restrictions still in place, NICUs are starting to move these online, and as the world adapts to the long haul with coronavirus, perhaps a more innovative (and virtual) support network is needed to ease the transition out of the NICU.

10. Insert joy where possible

Whilst the NICU is an intense environment, it can also be marked with life-changing moments of joy as babies hit particular milestones. A child opening their eyes for the first time, the first ‘smile’ (if it really is a smile), a particularly cute reaction, or the first skin-to-skin time between parent and child.

Several parents have found innovative ways to insert joy as they prepare for discharge from the NICU, whether making (or purchasing) crochet NICU graduation sets, planning for a particular family discharge photo as they leave the hospital, decorating the car and home to welcome the newborn home. Among Covid-19, this has helped inject some levity, humor and joy, and help others follow the newborn along their journey.

It also gives great joy to the Doctors, Nurses and NICU team who have cared deeply for every child in the NICU.

The NICU is a place of constant innovation

As the world learns more about Covid-19 and the impact on parents, staff and newborns, NICUs around the world will continue to develop new innovations that will strengthen the parent-child bond, and also ensure every NICU baby has the best possible start in life.

With Covid-19, not all birth policies have gone smoothly. New York Governor Cuomo initially placed a ban on both parents being in present for the birth, and after over 600,000 signed a change.org petition supporting expecting parents, had to reverse this decision. There has not been any discernible rise in Covid-19 linked to this decision.

As the coronavirus has spread around the world, necessity has become the mother of invention, forcing hospitals and society to rapidly react in the early months of the pandemic. With fragile babies, we have seen how the love of parents and the care team has driven innovation within NICUs even amidst these challenges.

It will be with this openness and innovation, that we can ensure the best start in life for some of the world’s most fragile humans, as we celebrate new life in the age of Covid-19.