Developmental care (DC) is care aimed at fostering the neurosensory and emotional development of neonates. The core principles of this type of care are reducing stress, adopting interventions that support infants, recognising the family as a constant point of reference in their lives, even while they are in hospital, and seeing the two (neonate and family) as a unit.1 Family members are integrated into care, form an essential part of it and participate in decisions about their child. DC involves a change of attitude in professionals, who have to adapt their practices to a new health care paradigm.

This type of care is widely established in many European countries. Northern countries have pioneered the change; in southern Europe, however, DC is not yet part of the routine of some units.2 In Spain we have had information about the implementation of DC since 1999.3 At that time, the presence of parents in neonatal units was almost negligible. In 20064 the results of a questionnaire sent to all neonatal units were published. This study showed the extent to which DC was established in Spain. In the last few years, the application of DC in Spanish units seems to have improved substantially, and for this reason the authors of this article decided to send out a new questionnaire to ascertain the level of implementation of DC in Spanish units where more than 50 children weighing under 1500g are cared for per year and to compare the results with those obtained in 2006.

Table 1 lists the public hospitals that cared for more than 50 children weighing under 1500g per year. The response rate in 2012 was 81% (22/27); in 2006, a response rate of 96% (26/27) was obtained.

Light and noise control in units

In 2012, 91% (20/22) of the units surveyed used canopies or coverlets over the incubators to provide protection from light versus 65% (17/26) in 2006 (P=.03). As for noise pollution in the units, 73% (16/22) had noise-reduction measures in place in 2012 versus 11% (3/26) in 2006 (P<.01). In 2012, 45% (10/22) of the units continuously measured the noise level. Fig. 1 shows what health care professionals consider to be the main sources of noise.

Figure 1.

Principal sources of noise in neonatal intensive care units according to the professionals surveyed in units that care for more than 50 children with birth weight under 1500g per year, in 2012.

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Pain management

Fig. 2 shows the comfort measures used before/during painful procedures in the intensive care area in 2012. Of the units surveyed, 41% (9/22) reported that they had a person dedicated exclusively to attending to infants and comforting them during painful procedures, although not continuously. A written protocol for pain management was in place in 73% (16/22) of the units. Sucrose was used as an analgesic when performing any maneuver that could be assumed to cause discomfort in 50% (11/22) in 2012 versus 46% (12/26) in 2006 (P=.6).

Figure 2.

Comfort measures used in the intensive care area before/during painful procedures in units that care for more than 50 children with birth weight under 1500g per year, in 2012.

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Policy towards parents and family members

In 2012, 82% (18/22) of the units allowed parents to be with their children in the intensive care area at any time of day, compared with 11% (3/26) in 2006 (P<.01). Fig. 3 shows the procedures during which parents, in 2012, were allowed to accompany their children. In 2012 50% of the units (11/22) had a rest room for parents versus 35% (9/26) in 2006 (P=.28).

Figure 3.

Procedures at which parents are allowed to be present in units that care for more than 50 children with birth weight under 1500g per year, in 2012.

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As regards kangaroo care (KC), in 2012 82% (18/22) of the units allowed mothers to practice KC without limitations, compared with 31% (8/26) in 2006 (P<.01). In 2012, 73% (16/22) of the units routinely allowed the father to do KC. Other family members were occasionally allowed to perform KC in 9% (2/22) of the units.

Fig. 4 presents the limitations on the practice of KC, in the opinion of the professionals in the units surveyed in 2012. Fig. 5 summarises the comparison of the results obtained in the 2005 questionnaire with those from 2012.

Figure 4.

Situations are not allowed which prevent Kangaroo Care being performed in neonatal intensive care units according to the professionals surveyed in units that care for more than 50 children with birth weight under 1500g per year, in 2012.

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Figure 5.

Graph comparing the data obtained in 2005 and 2012 from units that care for more than 50 children with birth weight under 1500g per year

* Statistically significant difference.

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Fig. 6 illustrates the development of policies on parental access according to the data provided in the studies by Cuttini et al. in 1999,3 Perapoch López et al. in 2006,4 as modified, Greisen et el. in 20092 and those obtained in this 2012 study.

Figure 6.

Frequency of unrestricted parental access to Spanish neonatal units from 1999 to 2012.

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This study provides information on the state of DC in 2012 in Spanish neonatal units that care for more than 50 newborn infants weighing under 1500g per year and compares it with the situation in 2006. The results obtained show that during the period from 2006 to 2012 there has been a clear improvement in policies on parental access to units, application of KC and use of noise and light control measures; in other types of care, however, conditions have changed to a lesser degree.

The first study published by Cuttini et al. in 19993 found that unrestricted parental access to neonatal units was almost non-existent. Gradually units became more accessible to families, but not until 2012 do we see them adopting a fully open policy. There has been an improvement in this respect, but further progress needs to be made so that parents are not mere spectators but play an active part in the care of their children. In many Spanish units, as the results of our study show, limits are still placed on the presence of parents when some technique or procedure is to be performed on the child. Several studies have demonstrated that contact between parents and their child during hospitalisation enhances the bond with the child6 and encourages interaction.7 Besides, the child's family is his or her natural environment and it should not be necessary to demonstrate any additional benefit in order to justify the need for children and their parents to be together.

As for KC, many units have also incorporated this type of care on a routine basis, so that in 2012 it is performed in most neonatal units. The fact that units have opened their doors to parents has certainly contributed to the implementation of KC. This is an encouraging development; but it is not yet widespread practice. In a recent study, Spain emerged once again as one of the European countries that most restrict the application of KC.5 Wide disparities in the use of KC are still evident among units; the creation of protocols agreed by all the professionals involved would probably reduce these differences. With this in mind, the guides provided by the World Health Organization could be very helpful.8

With regard to the macro-environment, a significant advance can be observed in noise control. Many neonatal units measure the noise level continuously with sound meters and make use of noise-reduction measures. This greater concern for noise will probably help parents who hear sounds when they are with their children (machines, alarms) that are not familiar to them and that they do not know how to interpret; this makes them anxious and worried and impedes communication with health care staff and even with their own child.9 Parents can be allies to professionals in achieving quiet neonatal units and avoiding the stress caused by noise, which has such a serious effect on children and parents.10 Despite the increase in noise control, almost half the units still did not measure noise levels at all in 2012.

There were also more units in 2012 that had introduced measures to provide protection from light, so that 91% of the units applied some means of controlling it, such as the use of coverlets or canopies. Despite the high level of implementation of some ambient light control procedures, measures for reducing light intensity are the least favourably regarded by professionals of all those related to DC.11

The use of nests to encourage correct posture is almost universally established. In 2006 the level of implementation was already high, and the increase was therefore not significant.

It is striking that administration of sucrose as a non-pharmaceutical analgesic remains at a low level, since although it has increased slightly in the last few years, only 50% of the units used sucrose in their daily routine in 2012. Nor do they routinely use other non-pharmacological analgesic measures that are easy to apply. These data are consistent with those published in a recent study,12 which reveals that the means employed for pain control during such common procedures as heel prick are insufficient and still rarely implemented in most participating European countries. Many studies have demonstrated the importance of minimising and controlling pain, given its short- and long-term effects on premature infants.13,14 In the light of these results, the use of sucrose15 and other measures to achieve greater comfort and adequate pain control should be encouraged.

A limitation of this study is that the information was collected using questionnaires and not by direct observation of the units. Nevertheless, all the data with which we have compared it was collected in the same way, and therefore the positive trend we have identified in implementation of DC very probably reflects the day-to-day situation in the units. Another limitation arises from the fact that the first study we used to compare parental admission policy3 does not use the same criterion for selecting units as the other studies with which we have made comparisons. The frequency of unrestricted parental access in that first study was very low. Even if the number of units allowing parents unrestricted entry was underestimated because of the way the units were selected, in view of the trend in later studies it is very unlikely that the rate was much higher at that time in units that care for more than 50 infants weighing under 1500g per year. Furthermore, the 2006 and 2012 questionnaires were handled anonymously, and therefore no unit-by-unit comparisons have been made, because as the professionals were informed when they were asked for the information, the analyses were performed on an anonymous basis.

This study reveals the major change that is taking place with regard to DC in the neonatal units with the highest level of care in Spain. The degree to which it is applied has increased significantly in the last few years, and the very significant change which has taken place in policies on parental access to neonatal units must be emphasised. The results obtained in this study are very positive, but we have identified certain issues, including such important matters as prevention and treatment of pain, that still require attention from the teams of professionals, in order to achieve continuing improvement in the quality of care provided.

The authors have no conflicts of interest to declare.