Medicosnext
Dr. Sajal Twanabasu
He is a pediatrician currently working at KIOCH, Kathmandu Children’s Hospital, with a positive attitude, patience, and commitment to excellence in child health. An avid reader with a strong interest in research and continuous skill enhancement. He has extensive experience working in a rural setting at Dhading, and played a key role in strengthening pediatric and neonatal services in the periphery. He has led and mentored nursing teams to ensure effective functioning of Level II neonatal care units in Dhading Hospital.
A firm advocate of Mother Baby Friendly Hospital Initiatives (MBFHI) and Infant and Family Centered Developmental Care (IFCDC). He serves as a facilitator and mentor for multiple neonatal training programs including FBIMNCI, CBIMNCI, SNCU orientation, MBFHI, and IFCDC.
The Takeaway Message (Separate Box on the title page)
Surviving is not the same as thriving. While the world, including Nepal, has made historic progress in cutting neonatal death rates by half, a silent crisis remains for the survivors. As medical science saves more premature babies, these fragile infants are often transferred from the protective womb into the stressful environment of Neonatal Intensive Care Units (NICUs). Here, bright lights, noise, and separation from parents disrupt critical brain development, leaving many survivors with long-term learning and behavioral disabilities.
“Survival of small and sick newborns occurs at the cost of developmental, cognitive, sensory, motor, emotional, and social deficits.”
The solution lies in a paradigm shift known as Infant and Family Centered Developmental Care (IFCDC). This evidence-based approach transforms parents from passive visitors into active partners on the healthcare team. IFCDC prioritizes neuroprotection by creating a soothing sensory environment, minimizing pain, and encouraging constant connection through methods like Kangaroo Mother Care (skin-to-skin contact).
“Families are no longer treated like visitors, but they are members of the caregiving team; partners of health care provider.”
Despite hesitation from some healthcare providers regarding infection risks—a fear debunked by research—integration of families is essential. IFCDC not only reduces stress for the baby but also alleviates parental anxiety, boosts breastfeeding rates, and shortens hospital stays. To truly honor our duty to future citizens, healthcare systems must move beyond simply saving lives. We must adopt IFCDC as a standard of practice, ensuring that every newborn is given the nurturing foundation required to reach their full potential.
Surviving, but are they thriving?
Across the globe, great strides have been made in reduction of neonatal mortality rate (NMR). Between 1990 and 2021, NMR across the globe decreased by approximately 51%, from 37 deaths per 1000 live births to 18. Nepal has followed a similar trajectory with NMR declining from 50 per thousand live births in 1996 to 21 per thousand live births in 2016 due to immense efforts by the Ministry of Health and Population and partners. With advancement in neonatal care, we have been able to progressively save more and more extreme premature babies. While mortality reduction has understandably been our focus, estimated prevalence of overall neurodevelopmental impairment, cognitive impairment and cerebral palsy for survivors of prematurity/very low birthweight has been noted as 21.4%. Hence, our focus should not only be directed towards saving lives of newborns, but we must also strive to mitigate the increased risk of disabilities to help them thrive and achieve their full potential in life.
“Studies have shown that the rate of infection doesn’t increase by allowing parents at neonatal unit all time.”
Preterm babies are usually transferred from the protected optimal environment in utero, separated from their parents and are transferred to the noxious sensory environment in SNCUs and NICUs. Such infants are exposed to excessive forms of stress, such as high levels of sound and lights in the unit, sleep disruptions, along with the number of painful and stressful procedures. As brain development occurs at unprecedented rate during the early days, babies exposed to excessive sensory stress will have negative impact on brain growth resulting in lower IQ. Hence, survival of small and sick newborns occurs at the cost of developmental, cognitive, sensory, motor, emotional, and social deficits.
Moreover, the bonding process between mother and baby that starts during pregnancy may be abruptly disrupted on admission of baby to the neonatal care unit. Separation devoid infants from the loving care of parents, which can have a negative impact on survival and depletes the baby from the opportunity to thrive. Separation not only affects a small and / or sick newborn, but it may also lead to frustration, anxiety and distress to the parents.
Infant and Family Centered Development Care (IFCDC) – to ensure they also thrive
IFCDC is evidence based on science of neurodevelopment, parent-infant interaction, parental involvement, breast feeding promotion, environmental and system adaptation. As depicted in the figure below, the infant is central to IFCDC.
Emphasis is laid on protecting infant’s developing brain and promoting optimal long-term neurodevelopmental and behavioral outcome by creating an enabling sensory environment that focuses on the protection these senses. The enabling sensory environment is thus established through proper positioning and handling, safeguarding sleep, minimizing stress and pain, protecting skin and optimizing nutrition. This can all be achieved by partnering with families and supporting them for interactions with their newborns. By increased parental bonding on one hand and minimizing the noxious effects of environmental stress, IFCDC creates possibilities for the baby to survive and thrive. Brain neuroplasticity provides opportunity for potential compensatory mechanisms and hence every effort should be made to provide sensory stimulating environment to small and sick newborns.
IFCDC is an approach that aims to develop partnership between the family and the health care team in delivering care for a neonate. Families are no longer treated like visitors, but they are members of the caregiving team; partners of health care provider. The partnership is based on the core principles of dignity, respect, information sharing participation and collaboration.
A Win-Win for All
Partnering with parents in care will provide them with adequate information about babies, develop confidence, which will eventually lead to satisfaction and reduced stress. Parents will be able to recognize infant’s signals and interpret the behavior of child. This will support the process of becoming a parent. Furthermore, parents will be more comfortable with care procedures, increase the chance of early skin to skin care and successful breastfeeding. This will reduce depression and anxiety among the parents.
Kangaroo Mother Care (KMC) care, that promotes prolonged skin-to-skin, early initiation of and exclusive breastmilk feeding is a well-established intervention included in our national policies and protocols. KMC not only promotes bonding, but several studies have revealed it also stabilizes heart rate, oxygenation and improves sleep which affects brain development of the newborn. IFCDC, by promoting 24/7 access for the parents with their newborn in the unit, creates a very suitable environment for KMC.
In summary, IFCDC creates a nurturing environment that reduces stress for parents and newborn, enhances parent-baby bonding, helps in promoting exclusive breastfeeding and growth, supports child’s neurodevelopment, helps to prevent disabilities and decreases duration of hospital stay.
Why is IFCDC not a norm of practice in SNCUs and NICUs?
The fear of spreading infection when IFCDC is practiced is the major reason for hesitancy in it’simplementation. There are strict visiting hours at neonatal care unit. However, studies have shown that the rate of infection doesn’t increase by allowing parents at neonatal unit all time.
Resistance by health care providers who so far have had exclusive right to the care of small and / or sick newborns is another fear that needs to be overcome. Health care providers should be motivated and their confidence need to be built before IFCDC can be implemented. They should be trained and adequately educated to collaborate and partner with family on shared responsibility. It requires lot of effort and dedication from both health care providers and families.
The journey towards IFCDC seems very long and difficult; however, with everyone’s effort and dedication we can definitely reach the destination. Above all, we need to know that every newborn has the right not only to survive, but also be given the care that will ensure they also thrive and reach their full potential. Health providers and policy makers should make every effort to ensure IFCDC is a norm – it is our duty towards the future citizens of our country.
At KIOCH, we are committed to embedding IFCDC principles across all neonatal units, reinforcing compassionate, family-centered care as a core standard of practice.
References:
UN IGME. Levels & trends in child mortality: report 2018. Estimates developed by the United Nations inter-agency group for child mortality estimation (UN IGME). New York: United Nations Children’s Fund; 2018
2. K. M. Milner, E. F. G. Neal, G. Roberts, A. C. Steer & T. Duke (2015) Long-term neurodevelopmental outcome in high-risk newborns in resource-limited settings: a systematic review of the literature, Paediatrics and International Child Health, 35:3, 227-242, DOI: 10.1179/2046905515Y.0000000043
