Caring for preterm babies in single family rooms may help prevent sepsis and improve exclusive breastfeeding: But single family rooms seem to have little effect on long-term neurodevelopment

Caring for preterm babies in single family rooms appears to reduce the incidence of sepsis and improve exclusive breastfeeding rates compared with traditional open ward neonatal units, according to a systematic review and meta-analysis published in The Lancet Child & Adolescent Health journal.

Nevertheless, extremely preterm babies (<28 weeks gestation) in intensive care looked after in single family rooms do not appear to have better neurodevelopmental outcomes at 18-24 months of corrected age (for prematurity) compared with those cared for communally in open bay units.

The authors say that the findings support the growing trend towards building more single family rooms in neonatal units. Sepsis (which affects around a quarter of babies born extremely preterm) and establishing breastfeeding during hospital stay are major challenges for preterm infants, and both are associated with cognitive outcomes in the long term. However, they caution that the true effect of single family rooms on long-term cognitive outcomes remains unclear because of the small number and short follow-up of studies assessing neurodevelopment, and the lack of randomised controlled trials.

“Our findings support future development of single family rooms in neonatal units to reduce sepsis and improve breastfeeding rates during hospital stay. But to establish whether single rooms have an impact on long-term neurodevelopment we also need well-designed studies to examine the vast majority of preterm infants who are born after 32 weeks gestation, in whom no follow-up studies have been done,” says Dr Sophie van der Schoor from OLVG (a teaching hospital in Amsterdam), Netherlands, who led the study.

Prematurity is the main complication of pregnancy, and 14.9 million babies are born preterm (delivery before 37 weeks of gestation) worldwide every year. Delivery at any gestation other than full term can impair brain development, increasing the risk of poor neurocognitive outcomes.

Preterm babies often spend their first months after birth in neonatal intensive care units and are usually cared for communally in open bay units. Nurses provide routine care and parents are welcome in most units at any time. Concerns that unfavourable environmental factors including excessive stimulation from noise and lights, separation from parents, and infections may jeopardise neurodevelopmental outcomes and survival have contributed to a rise in hospitals building private rooms instead of open bay units. However, the potential benefits and harms that the hospital environment has on the health, particularly neurodevelopment, of preterm babies is hotly debated. Research so far has produced conflicting results.

The researchers based their findings on a systematic review and meta-analysis of all studies conducted in developed countries examining clinical outcomes of preterm infants cared for in single family rooms compared with open bay units between 2004 and 2018. Data were analysed for 13 distinct study populations (ie, infants from the same hospital admitted during the same time period) in 25 papers including 4,793 preterm babies. Data on neurodevelopment was available for three study populations, totalling 680 infants. Children were assessed for their cognitive, motor, and language development using a standardised test of infant development at the corrected age (for prematurity) of 18-24 months.

Analysis of data from these three study populations including only extremely preterm infants (average gestational age <28 weeks; average birthweight <1000 g) showed that neurodevelopment at the corrected age of 18-24 months was not significantly different between babies cared for in single family rooms and open bay units.

Studies focusing on sepsis seemed to show a different picture, with significantly (37%) less risk of sepsis in single family rooms compared with open bay units (97/2055 participants vs 170/2110) — equivalent to one less sepsis event per 1000 hospitalisation days.

Nine studies (five populations) looking at breastfeeding found similar benefits — once discharged, babies cared for in single family rooms were 31% more likely to be exclusively breastfed compared to the open ward group (101/266 vs 68/218).

There were no differences in length of hospital stay (from birth to discharge home), rates of growth, bronchopulmonary dysplasia (a chronic lung disease), retinopathy of prematurity (a rare cause of blindness in premature babies), intraventricular haemorrhage (brain bleeding), or mortality.

“Although our study is based on all available data in the public domain, we did not find clear evidence of benefit of single family rooms on neurodevelopment. However, in all studies, outcomes were only assessed up to 2 years old, and some children who experience cognitive difficulties at school are classified as having normal neurodevelopmental function at 2 years of age. Even for cases of severe cognitive deficit at later ages in childhood the accuracy of early detection is low. As neuro-cognitive deficits often take a long time to develop, more and longer follow-up studies are needed,” says van der Schoor.

The authors note that the study included only one randomised trial and also point to several limitations, including that some papers assessed the same patient population, and without access to individual patient data it is difficult to get accurate effect estimates. They also highlight some methodological limitations including selection bias and confounding (only participants with potentially high parental presence during hospital stay were included or differences between populations might already have been present at start of the intervention) — which limit the conclusions that can be drawn.

Commenting on the implications of the study, Dr Jayanta Banerjee from Queen Charlotte’s and Chelsea Hospital, London, UK says: “Van Veenendaal and colleagues have rightly argued that the benefits shown in their study should be considered by healthcare policy makers and stakeholders assessing future development of single family rooms in neonatal units. But single family rooms also have some inherent disadvantages. The parents might feel more isolated from other parents and health-care professionals when caring for their infants in single family rooms, which might have deleterious effects on their stress and anxiety. The staffing in a neonatal unit would require rearrangement to cater for single family room care. Finally, provision of single family rooms would require major restructuring in most neonatal units, which would have a substantial economic effect on health-care costs and resources. Therefore, when building new neonatal units or redeveloping existing units, single family rooms should be seriously considered.”

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