Family-centered care in the neonatal intensive care unit: a meta-analysis and systematic review of outcomes for preterm infants
Original Article

Family-centered care in the neonatal intensive care unit: a meta-analysis and systematic review of outcomes for preterm infants

Shuang Chen1, Hong Shen2, Qiuhong Jin1, Liangping Zhou1, Lin Feng2

1Department of Neonates, People’s Hospital of Suzhou High-tech Zone, Suzhou, China; 2Department of Neonates, The Affiliated Suzhou Hospital of Nanjing University Medical School, Suzhou, China

Contributions: (I) Conception and design: S Chen, L Feng; (II) Administrative support: L Feng; (III) Provision of study materials or patients: S Chen; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: S Chen, H Shen; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Qiuhong Jin, BSN. Department of Neonates, People’s Hospital of Suzhou High-tech Zone, No. 95 Huashan Road, Suzhou 215011, China. Email: 523994489@qq.com; Lin Feng, BSN. Department of Neonates, The Affiliated Suzhou Hospital of Nanjing University Medical School, No. 1 Lijiang Road, Suzhou 215011, China. Email: zbn718@sina.com.

Background: The efficacy of family integrated care for preterm infants is not well established. This meta-analysis aims to assess the impact of family-integrated care on preterm infants to inform neonatal clinical practices.

Methods: We conducted a literature search in PubMed, Cochrane Library, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), Weipu, and Wanfang databases up to August 25, 2024. Two researchers independently screened articles, applying predefined inclusion and exclusion criteria, and performed quality assessments and data extraction. Meta-analysis was conducted using RevMan 5.3 software.

Results: Thirteen randomized controlled trials (RCTs) were included, encompassing 3,005 preterm infants, of which 1,390 received family-integrated care. Family-integrated care significantly improved breastfeeding rates [odds ratio (OR) =5.92, 95% confidence interval (CI): 2.37 to 14.82, P<0.001], weight gain [mean difference (MD) =3.16, 95% CI: 2.51 to 3.80, P<0.001], and sleep duration (MD =3.25, 95% CI: 2.05 to 4.44, P<0.001) in preterm infants and reduced the one-month readmission rate (OR =0.37, 95% CI: 0.22 to 0.61, P<0.001). Egger’s regression test indicated no publication bias among the outcomes (all P>0.05).

Conclusions: Family-integrated care markedly improves breastfeeding rates, promotes weight gain, and extends sleep duration in preterm infants, while concurrently reducing the likelihood of hospital readmission. This approach offers substantial benefits to both the preterm infants and their families, highlighting its potential for wider implementation in neonatal nursing practice.

Keywords: Care; family; infants; nursing; preterm

Submitted Sep 16, 2024. Accepted for publication Dec 03, 2024. Published online Jan 21, 2025.

doi: 10.21037/tp-24-373

Highlight box

Key findings

• Family-centered care has been associated with significant improvements in breastfeeding rates, enhanced weight gain, and prolonged sleep duration among preterm infants.

What is known and what is new?

• The involvement and care provided by family members play a significant role in the prognosis and well-being of preterm infants.

• Family-centered care has been observed to decrease the risk of hospital readmission.

What is the implication, and what should change now?

• Family-centered care provides substantial benefits to both the preterm infants and their families, suggesting its potential for broader application in neonatal nursing practices.

Introduction

Preterm infants refer to live babies born before 37 weeks of gestational age, which are born ahead of time due to internal and external factors (1). It has been documented that approximately 15 million infants are born preterm globally each year, with an estimated 1.2 million of these births occurring annually in China. This figure is noted to be on the rise, with an increasing trend observed year over year (2,3). The organs of preterm infants are not yet mature, and the incidence of complicated disease is higher than that of full-term infants (4). Most preterm infants are sent to neonatal intensive care unit (NICU) for treatment after birth. Due to incomplete development and limited thermogenic system, the body temperature of preterm infants is unstable and difficult to regulate, and the resistance to various infections is very weak, preterm infants are often accompanied by complications (5,6). With the substantial increase in the survival rate of preterm infants, how to improve the quality of life of preterm infants has become the focus of social attention (7). At present, NICU is still in closed management around the world, ignoring the positive role of the family, resulting in the separation of mother and baby, limiting the physical and emotional interaction between parents and infants, parents have only a little time to visit and accompany the infants, and some parents often find it difficult to fulfill reasonable parenting behavior after the infant being discharged from hospital, which can easily lead to negative emotions such as anxiety and depression (8,9).

Many previous studies (10-12) have shown that parental care plays an important role in the growth and development of preterm infants. Family-integrated care represents an innovative nursing paradigm that fosters parental involvement in the pediatric care process under the supervision of healthcare professionals. This model aims to cultivate a cohesive and supportive healthcare setting that is conducive to the well-being of children (13,14). Family integrated care model is a new nursing method, which emphasizes the important role of parents in the growth and development of preterm infants, and forms a treatment system among medical staff, parents and preterm infants (15). After professional education and training, the parents may participate in all kinds of non-medical nursing, which can help parents better understand and various physiological and psychological needs of preterm infants (16,17). Several studies have reported the effect of family integrated care model on preterm infants, and the results are different and inconsistent. Therefore, the purpose of this study is to systematically evaluate the effect of family integrated care model on preterm infants to provide scientific basis for improving the nursing quality of preterm infants. We present this article in accordance with the PRISMA reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-24-373/rc).

Methods

Literature inclusion and exclusion criteria

The inclusion criteria of this meta-analysis were as follows: the type of study was a randomized controlled trial (RCT); the study population were preterm infants whose gestational age was less than 37 weeks. The intervention group was treated with family integrated care on the basis of routine nursing of preterm infants, and the control group was treated with routine nursing of preterm infants without family participation. Outcome indicators: breastfeeding rate of preterm infants, weight gain of preterm infants, sleep time of preterm infants and the one-month readmission rate.

The literature exclusion criteria were as follows: repeatedly published literature, cases, reviews, conference papers, and literature reports in which the outcome index could not be extracted after contacting the corresponding authors.

Literature retrieval strategy

The authors searched for published RCTs about the effect of family integrated care pattern on preterm infants. The retrieval databases included PubMed, Cochrane Library, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), Weipu and Wanfang databases. The search strategy of this meta-analysis was as follows: (“newborn” OR “infants” OR preterm “OR” preterm infants “OR” preterm “OR” preterm infants “OR” prematurity “OR” neonatal “or” neonatal prematurity”) AND (“family integrated care “OR” FIC “OR” family integrated nursing”) AND (“randomized controlled trial “OR” clinical trial “OR” RCT”). The time limit for retrieval was from the establishment of the database to August 25, 2024. The search languages were limited to Chinese and English.

Literature screen and data extraction

After browsing all the titles and abstracts of the literature retrieved by the two authors, the obviously irrelevant studies were excluded. Then we read the full text of the relevant literature and screened the literature according to the inclusion and exclusion criteria. In the event of a dispute, the third author would assist in evaluating the matter, and a consensus would be reached through discussion. After reading the full text, the research data including characteristics of study population, details of intervention measures and outcomes were extracted.

The quality evaluation of included RCTs

Two researchers used the Cochrane bias risk tool to assess the bias risk of included RCTs: whether it was RCT, randomized concealment, blind trial intervention and outcome evaluation, incomplete outcome data processing, selective reporting, risk of early termination of the trial, whether the baseline was balanced between the trial group and the control group, and whether there was bias from sponsors. Each evaluation content could be evaluated as low-risk, high-risk or unclear.

Statistical analysis

We used RevMan5.3 software for meta-analysis. For the results of binary variables, it was expressed by odds ratio (OR) and 95% confidence interval (95% CI), and for continuous variables, it was expressed by mean difference (MD) and 95% CI. The heterogeneity among the included studies were tested by I2 test. If I2>50% suggested a high degree of heterogeneity, a random effect model was used. If I2 was less than 50%, there was no significant heterogeneity between studies, and a fixed effect model was used. Funnel chart and Egger regression analysis were used to analyze the publication bias of the study. When P<0.05, the difference was statistically significant.

Results

Study selection

Initially, a comprehensive search yielded a total of 620 articles. After rigorous screening, 565 articles were excluded due to non-adherence to the inclusion criteria or duplication. This process left us with 55 full-text articles for further review. Upon closer examination, an additional 42 articles were deemed ineligible based on the predefined criteria. Finally, 13 RCTs (18-30) were included for meta-analysis (Figure 1).

Figure 1 The PRISMA flow diagram of RCT selection. RCT, randomized controlled trial.

Characteristics of included RCTs

As shown in Table 1, of the included 13 RCTs (18-30), a total of 3,005 preterm infants were involved, 1,390 preterm infants received family integrated care, and 1,615 preterm infants received routine nursing care. After training, the family members could take care of the preterm infants together with the medical staff, and the family members could participate in non-medical nursing operations.

Table 1

The characteristics of included randomized controlled trials (RCTs)

RCT Sample size Birth weight (kg) Gestational age (weeks) Family integrated care measures Outcomes
Family integrated care group Control group Family integrated care group Control group Family integrated care group Control group
Cheng 2023 35 35 0.98±0.16 0.95±0.18 26.79±0.82 26.67±0.73 The parents were taught by the team members, including the significance of family-based nursing, participation process, participation methods, ward management regulations. They made telephone or WeChat follow-up after discharge, to understand the children’s home upbringing, and to provide professional and effective home nursing guidance in time Occurrence of hypothermia, time of unplanned reoxygenation therapy, time of complete oral feeding, length of stay, weight gain, re-hospitalization
Gao 2023 41 41 2.12±0.75 2.01±0.49 32.17±1.61 31.75±1.38 Online autonomous learning and offline scenario simulation, teaching demonstration, parental practice, assessment and other ways to carry out mixed parental education and training, parents provide premature infants with breastfeeding, oral care, non-nutritive sucking, touching, changing diapers, temperature measurement, bathing, kangaroo care, etc., accompanied throughout the nursing process, responsible for nursing quality control Growth rate of body weight, feeding intolerance, breastfeeding rate, readmission rate within 30 days
Hei 2018 212 215 1.62±0.37 1.67±0.33 31.40±1.80 31.70±1.70 Family members were trained to enter the NICU to take care of premature infants with medical staff, and family members can participate in non-medical nursing operations Body weight growth rate, breastfeeding rate
Hou 2018 35 35 1.36±0.11 1.33±0.13 30.93±1.70 31.44±2.40 The training of neonatal nursing knowledge was carried out by the combination of video broadcast classroom lectures and operation demonstration. The parents accompanied the child and undertake all the non-medical routine life care, independently complete the feeding, skin care and learnt to observe the abnormal symptoms of the newborn, and the nurses provide bedside guidance at any time Body weight growth rate, breastfeeding rate, mother’s negative emotion
Li 2018 30 30 1.62±0.20 1.60±0.21 34.10±3.92 33.38±3.12 Nursing staff guided and helped family members to independently complete the related life care of premature infants. Nurses were followed up once a week to answer questions related to family members after discharge, and to investigate the development of premature infants for a total of 6 months Sleep time, body weight change
Lou 2018 49 46 1.67±0.24 1.65±0.21 29.61±1.80 29.62±2.23 The nurses explained the correct methods of feeding, oral care, back slapping, atomization, monitor data, changing diapers, taking body temperature, cuddling posture, sputum suction and so on. Family members could use all kinds of toys or children’s songs to amuse the child when he wake up, and at the same time can do some simple touching and passive exercises. The family members can accompany the child for no less than 3 hours a day until the child was discharged from hospital Breastfeeding rate of preterm infants, weight gain of preterm infants, sleep time of preterm infants, the readmission rate within 1 month
Lu 2019 150 150 1.89±0.69 1.94±0.58 28–37 28–37 Parents dressed, bathed, positioned, fed, record oral drug doses, changed diapers, participated in relevant ward rounds and timely reflected nursing problems, registered the weight of premature infants, participated in the formulation of nursing plans, and observed the daily recovery of premature infants Body weight growth rate, breastfeeding rate, mother’s negative emotion
O’Brien 2018 396 624 1.41±0.38 1.44±0.47 22–33 22–33 Parents had to commit to be present for at least 6 h a day, attend educational sessions, and actively care for their infant Body weight growth rate, breastfeeding rate, mother’s negative emotion
Wang 2016 245 212 1.67±0.25 1.76±0.34 32.00±6.10 33.00±5.20 Nurses trained parents in accompany system, hand hygiene methods, feeding and daily nursing. Nurses guided kangaroo care and encouraged parents to participate in daily care Weight gain of preterm infants, the readmission rate within
1 month
Wang 2017 40 40 1.71±0.22 1.69±0.20 30.70±2.10 30.80±2.10 Parents were trained to enter the NICU to take care of premature infants with medical staff, and family members can participate in non-medical nursing operations Breastfeeding rate of preterm infants, the readmission rate within 1 month
Xiang 2016 30 60 1.71±0.38 1.89±0.39 31.80±2.10 32.60±1.70 The nurse instructed parents to record the general condition, body temperature, heart rate, body weight, stool and urine, milk volume, as well as parents’ daily experience, and to provide parents with nursing knowledge, skill guidance and psychological support at any time Growth rate of body mass, breastfeeding rate, readmission rate, nervous system development
Yang 2018 65 65 1.68±0.41 1.70±0.43 32.15±1.85 32.22±1.94 Nurses instructed parents to participate in non-medical routine life care of premature infants during hospitalization, they formulated detailed follow-up procedures and contacted them regularly Parents’ negative emotion
Zhang 2018 62 62 1.87±0.95 1.88±0.89 23.25±2.81 23.65±2.69 The medical staff explained in detail to parents the physiological structure and nursing methods of newborns, as well as simple first aid measures and common disease prevention and care of premature infants. The nurses carry out continuous nursing intervention for children and their families Nervous system development

Data are presented as number, mean ± standard deviation or range. NICU, neonatal intensive care unit.

Quality of included RCTs

As presented in Figures 2,3, the overall quality of the 13 RCTs was good. All the RCTs mentioned the method of generating random sequences, and only 4 RCTs introduced the allocation hiding method. The double-blind method was not introduced in detail in the included literature. All the included RCTs compared the baseline data of gestational age and birth weight between the intervention group and the control group, and the baseline data of the two groups were comparable.

Figure 2 Risk of bias graph.
Figure 3 Risk of bias summary.

Meta-analysis

Eight RCTs reported the effect of family integrated care on the breastfeeding rate of preterm infants. There was significant statistical heterogeneity among the studies (I2=92%, P<0.001). Random effect model analysis was selected for meta-analysis. The results showed that family integrated care could increase the breastfeeding rate of preterm infants (OR =5.92, 95% CI: 2.37, 14.82, P<0.001, Figure 4A).

Figure 4 Forest plots for the breastfeeding rate and weight gain of preterm infants. (A) Forest plot for the breastfeeding rate of preterm infants; (B) forest plot for the weight gain of preterm infants. M-H, Mantel-Haenszel method; SD, standard deviation; CI, confidence interval; IV, inverse variance.

Nine RCTs reported the effect of family integrated care on the weight gain of preterm infants. There was significant statistical heterogeneity among the studies (I2=80%, P<0.001). Random effect model analysis was selected for meta-analysis. The results showed that family integrated care could increase the weight gain of preterm infants (MD =3.16, 95% CI: 2.51, 3.80, P<0.001, Figure 4B).

Two RCTs reported the effect of family integrated care on the sleep time of preterm infants. There was no significant statistical heterogeneity among the studies (I2=0%, P=0.81). Fixed effect model analysis was selected for meta-analysis. The results showed that family integrated care could increase the sleep time of preterm infants (MD =3.25, 95% CI: 2.05, 4.44, P<0.001, Figure 5A).

Figure 5 Forest plots for the sleep time and 1-month readmission rates of preterm infants. (A) Forest plot for the sleep time a of preterm infants; (B) forest plot for the 1-month readmission rates of preterm infants. SD, standard deviation; IV, inverse variance; CI, confidence interval; M-H, Mantel-Haenszel method.

Five RCTs reported the effect of family integrated care on the one-month readmission rates of preterm infants. There was no significant statistical heterogeneity among the studies (I2=0%, P=0.55). Fixed effect model analysis was selected for meta-analysis. The results showed that family integrated care could reduce the one-month readmission rates of preterm infants (OR =0.37, 95% CI: 0.22, 0.61, P<0.001, Figure 5B).

Sensitivity analysis

In order to test the source of heterogeneity and the reliability of the combined results, a new meta-analysis was carried out by removing a study one by one, and the new combined effect and its heterogeneity were not significantly different from those before removal, indicating that the results of this meta-analysis were reliable.

Publication bias

We used the funnel chart (Figure 6) to evaluate the publication bias of the literature, the dots in the funnel plots were basically symmetrical, suggesting that the publication bias was small. The results of Egger regression test indicated that there was no publication bias amongst the synthesized outcomes (all P>0.05).

Figure 6 Funnel plots for analyzed outcomes. (A) Funnel plot for the breastfeeding rate of preterm infants; (B) funnel plot for the weight gain of preterm infants; (C) funnel plot for the sleep time a of preterm infants; (D) funnel plot for the one-month readmission rates of preterm infants. SE, standard error; OR, odds ratio; MD, mean difference.

Discussion

Family integrated care is based on the humanistic neonatal nursing model of Aishataria, which refers to a nursing mode that allows parents to participate in non-medical routine life care during hospitalization on the premise of education and guidance by neonatal specialist nurses (31). With the development of neonatal science, the original NICU closed management model can no longer meet the needs of preterm infants for the establishment of parent-child relationship during hospitalization and the requirements of parental care ability after the disease is cured and the infants return to the family (32,33). There is an urgent need for nurses to actively develop innovative consciousness and make reforms on the basis of the existing NICU closed management system to support parents of preterm infants to participate in the care of preterm infants directly at NICU (34). This model of involving family members in medical treatment and nursing decision-making of preterm infants is an important breakthrough and will be the development direction of neonatal nursing. The results of this meta-analysis have found that family integrated care is beneficial to improve the breastfeeding rate and weight gain of preterm infants, increase the sleep time of preterm infants and reduce the one-month readmission rates of preterm infants. With more RCTs included, our findings are consistent with previous report (35). Family integrated care should be promoted in clinical nursing care.

The traditional NICU implements closed management, and the separation of parents and infant makes the family relationship between parents and infant unsatisfied (36). On the one hand, it has a great impact on the parents’ psychology, increasing the mother’s negative emotions such as anxiety and depression, on the other hand, breastfeeding is difficult to be guaranteed (37). Previous studies (38,39) have shown that the breastfeeding rate of NICU preterm infants during hospitalization is less than 45%. Furthermore, the sleep patterns of preterm infants in the NICU are susceptible to disruption by factors such as lighting, noise, and medical interventions, which can potentially result in sleep disturbances (40,41). Family integrated care model emphasizes the role of family members to preterm infants, through a series of measures to make family members participate in the nursing of preterm infants in hospital, including feeding, touching, changing diapers, wiping bath and other life care, so as to promote the development of preterm infants to obtain professional care and sufficient emotional needs. Sleep is very important for newborns (42,43). During sleep, the secretion of growth hormone in preterm infants increases, their weight and height develop rapidly, and their meridian system continues to develop for a long time after birth, these processes are inseparable from good sleep (44). The findings of this study demonstrate that the implementation of a family-integrated care model significantly enhances the sleep duration of preterm infants, which is instrumental in promoting their developmental and growth trajectories. Within this model, parents of preterm infants are actively engaged in their children’s care, receiving professional guidance from healthcare providers. This enables them to acquire a deeper understanding of nursing knowledge and skills, facilitating the continuity of care post-discharge and potentially reducing the readmission rates of preterm infants (45).

It is a great challenge for medical staff to include parents in NICU to work with medical staff. Medical staff should focus on providing psychological support and help to parents and inform them of the significance, purpose and benefits of the family integrated care project (46,47). When the vital signs of preterm infants are stable, it is imperative to focus on the education and training of parents in care knowledge and skills. Concurrently, it is essential to address and refine the perceptions and awareness of medical and nursing staff. This involves bolstering the humanistic consciousness and literacy among healthcare providers and ensuring they offer robust psychological support to the parents of preterm infants. While prioritizing the treatment of preterm infants’ medical conditions, healthcare professionals must also be attentive to the emotional well-being and educational needs of the parents, to foster a comprehensive and supportive care environment (48). The cultivation of long-term care ability such as parental care and late rehabilitation of preterm infants after returning to home should also be considered and trained (49). Family integrated care model plays a positive role in promoting sleep and development of preterm infants, it is worth further popularizing and applying in clinical care.

There are some limitations in this meta-analysis. First of all, the number of included literatures is limited, and the research reports are mainly from China and Canada, which may have regional and demographic deviations. Secondly, the inclusion of RCTs has some deficiencies in the setting of blind method. Finally, the intervention methods and contents of the included studies are different, there are also some differences in the included sample size and specific evaluation indicators. In the future, large samples, multi-center, strict design and high-quality RCTs are needed to analyze the role of family integrated care.

Conclusions

In conclusion, with 13 RCTs included, this meta-analysis has found that family integrated care is helpful to improve the breastfeeding rate, weight gain of preterm infants, increase the sleep time of preterm infants and reduce the one-month readmission rates of preterm infants. At present, more and more nursing models emphasize parents’ participation in hospitalized care of preterm infants. The concept of family-centered care requires medical managers to actively develop innovative consciousness and change the traditional concept of closed management of NICU. On the foundation of ensuring thorough family training and effective supervision, the family-integrated care model should be integrated into the NICU to enhance the prognosis of preterm infants.

Acknowledgments

Funding: This study was funded by Suzhou Medical Key Support Discipline Project (Nos. SZFCXK202110 and SZFCXK202109).

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-24-373/rc

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-24-373/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-24-373/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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Cite this article as: Chen S, Shen H, Jin Q, Zhou L, Feng L. Family-centered care in the neonatal intensive care unit: a meta-analysis and systematic review of outcomes for preterm infants. Transl Pediatr 2025;14(1):14-24. doi: 10.21037/tp-24-373

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