Sibling Visiting in a Neonatal Intensive Care Unit

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Sibling

Visiting

in a Neonatal

Intensive

Care

Unit

Fred

Schwab,

MD,

Brenda

Tolbert,

MSW,

Stephen

Bagnato,

PhD,

and

M. Jeffrey

Maisels,

MB, BCh

From the Division of Newborn Medicine, Departments of Pediatrics and Psychiatry, The

Milton S. Hershey Medical Center of The Pennsylvania State University, Hershey

ABSTRACT.

The effect of sibling visiting in a neonatal

intensive care unit was studied. Sixteen siblings of 13

infants were randomly assigned to a visiting or

nonvisit-ing group. Behavioral patterns were measured by ques-tionnaires administered to the parents and by direct

observation and interviews with the children. There were

no significant changes in the behavior of the children

following the birth of their sibling, and there was no significant difference between the behavior scores of the two groups 1 week after the experimental (or control) intervention. The visiting children did not show signs of fear or anxiety during the visit. These data suggest that sibling visiting to a neonatal intensive care unit is not likely to be harmful and might be beneficial to the siblings and their families. Pediatrics 1983;71:835-838; hospital

visiting, neonatal intensive care visiting.

Hospital visiting by children, once a subject of

considerable controversy,1 is becoming

common-place. Although children are allowed, sometimes, to

visit adult hospital patients and, occasionally,

healthy newborns,2 such visiting is very unusual in neonatal intensive care units (NICUs). The effect

of visiting by children in maternity units has been studied,3 and visits by adults to NICUs do not increase the risk of neonatal infection and are not

disruptive.4’5

Even under normal circumstances, a birth in the

family may be a traumatic event for young siblings.

The involvement of the parents in the approaching

birth, the absence of the hospitalized mother, and

the apparent displacement of parental love may

have a profound effect on the young child.6’7 When

the birth is premature or otherwise complicated,

Received for publication April 14, 1982; accepted July 6, 1982. Reprint requests to (M.J.M.) Department of Pediatrics, The Milton S. Hershey Medical Center, Hershy, PA 17033.

the baby often remains in the hospital for an ex-tended period, and this may exacerbate these dis-turbances.8 To our knowledge these potential

prob-lems have never been the subject of a formal study in a NICU; therefore, we examined the risks and benefits of allowing siblings to visit hospitalized neonates.

METHODS

The sample consisted of 16 siblings (aged 3.8 to 7.25 years, mean 5.15) of 13 infants admitted to the

Hershey Medical Center NICU between June 1979

and January 1981. Only siblings aged 4 to 7 years

were included because of the difficulty in interview-ing younger children, and because at this age we expected to see the severest impact7 and the most easily detectable behavioral regressions. The

sib-lings

were randomly assigned to a visiting group (n

= 8; mean age 5.2 years; five boys, three girls) or a nonvisiting control group (n = 8; mean age 5.15

years; four boys, four girls). Siblings were excluded

from the study if the infant’s hospital stay was anticipated to be less than 2 weeks. None of the infants died. Parents were not informed of their

children’s visiting status until they had agreed to

participate. Four children were removed from the

sample

because their hospitalized siblings were dis-charged prior to the termination of the study. All families were white, and combined family income was >$30,000 in three, $20,000 to 30,000 in one, $10,000 to 20,000 in eight, and <$10,000 in one.

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DAYS

836 SIBLING

VISITS

IN NEONATAL

INTENSIVE

CARE

UNIT

TABLE.

Charact eristics of Infants Visited in N eonatal Intensive Care Unit*

Infant Birth Gestation Diagnosis Hospital Course

No. Weight (g) (wk)

1 2,495 37 Congenital

pneu-monia

Spontaneous pneumothorax, chest tube

2 2,190 35 HMD Assisted ventilaton

3 1,520 31 TTNB Uncomplicated

4 936 29 IVH, apnea, and

bradycardia

Assisted ventilation

5 830 26 HMD Assisted ventilation, IVH

6 2,440 34 Twin B, HMD Assisted ventilation, bilateral

pneumo-thoraces, BPD

7 1,880 33 HMD Assisted ventilation

*Abbreviations used are: HMD, hyaline membrane disease; TTNB, transient tachypnea

of the newborn; IVH, intraventricular hemorrhage; BPD, bronchopulmonary dysplasia.

in the Table. The degree of interaction permitted varied with the status of each baby and ranged from simple touching through the incubator portholes to holding and feeding the infant.

Following the 15- to 30-minute visit, the child was interviewed by one of the investigators using a predetermined, consistent set of questions. The nonvisiting children were not permitted to see their siblings but were subject to the same interview. As it was necessary that the interview be performed by one of the investigators (who was aware of the visiting or nonvisiting status of the sibling) the possibility of bias existed during the interview. This was overcome, as far as possible, by using for each child a standardized set of nine questions that

required a relatively simple response, eg, “Why did you come to the hospital today? Do you want the baby to come home? Who will take care of you when the baby comes home?” etc. Transcripts of each interview were graded “blindly” by a clinical

psychologist, to assess the child’s reaction to the hospital and baby, his understanding of why the baby was hospitalized, and his concerns regarding

changes in the family structure after the infant’s discharge. The visiting group included one set of

siblings. They visited the infant together but were

interviewed separately. The experimental design is

shown in the figure.

Data were also obtained from a questionnaire

completed by the parents. This questionnaire was similar to one developed by Trause et al3 and asked

specific questions about the child’s behavior during the preceding two days in four areas of daily routine: eating, sleeping, toilet habits, and general behavior. Questionnaires were completed three times during the study. Immediately after NICU admission, par-ents were instructed to evaluate “two normal days in your child’s life prior to the birth of the infant.” This established the child’s base line of normal behavior. The second questionnaire was completed approximately 1 week after the baby’s admission to

BWth

-2 -1 0 1 2 3 4 5 6 7 8 9 10 11 t2 13 14

S.g Bsh.

=nnrni

S’’i lnt.,**

V6s1 H.p,tM. Nt

-Ptt,d

to

S.. B.by

v_I NICUFoliow.d

by Its* =

ContoI G’o.,p

G’op =

Figure. Experimental design and protocol.

the NICU, and just prior to the visit or control

interview. This documented the child’s behavior

after the first week of the neonate’s life. The third

questionnaire was completed 1 week after the visit or control interview; this measured behavior 1 week after the experimental intervention.

Trends in behavior were measured by comparing

responses from each questionnaire. Each aspect of

behavior (37 items) included in the questionnaire

was assigned a rank of from 1 to 3 based on its

significance as a problem behavior, eg, temper

tan-trums were rated 3, whereas playing with food was rated 1. The ranking system was devised by a

consensus of a child psychologist and two

pediatri-cians. A total behavioral score was computed for

each questionnaire and provided, in essence, a measure of negative, or problem, behavior. After

parents had completed the questionnaire, they were

requested to offer additional comments or obser-vations, especially if their child voiced any worries

or concerns following the visit.

Prior to each visit, parents were asked whether

their children were symptomatic for common viral

or other infectious diseases. No children were

ex-cluded

on this basis. An observer was present during each visit to record the child’s reactions, and the

hospital

course of each visited infant was examined

for the development of nosocomial infections.

The data were analyzed using analysis of variance and the Fisher exact test.

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RESULTS

No significant changes occurred in the behavioral

scores of either group following the birth of their

sibling, and there was no significant difference

be-tween visitors and nonvisitors. Following the hos-pital visit, the behavioral score of the visiting group improved, but the change was not significant and was not different from the change observed in the

nonvisiting group.

Complete interviews were obtained from five

vis-iting and six control children studied. The remain-ing five subjects would not respond to the

investi-gator’s questions. Four of the nonvisiting children gave responses graded as negative or fearful when asked to describe the hospital. All of the responses

by the visiting group were rated as positive or noncommittal. All of the visiting group were graded

positively in their acceptance of the baby’s antici-pated homecoming; however, two of the control

group gave ambivalent answers. Eighty-three per-cent of the subjects understood the reasons for their

sibling’s hospitalization.

All of the childrens’ responses demonstrated

con-cern for changes in the family structure following the homecoming of the baby. Each child verbalized his feelings that the mother would have less time to spend with her older children. When asked, “Who will take care of you when the baby comes

home?,” six children responded that they would take care of themselves or that their father would care for them.

Each visiting child was observed while in the unit. Every visit proceeded smoothly without dis-rupting patient care or activity in the NICU. The

visitors were led to their sibling’s incubator and,

after a short time, most were eager to touch the baby. Fifty-five percent of the children began by

touching the infant’s extremities, and proceeded to the baby’s head and chest. Most of the children

responded spontaneously, smiling and talking to the infant. Three children assumed the “en face”

position, in which the children’s and infants’ eyes

met in the same plane of rotation. Visiting children

older than 5 years were more hesitant, considered

the baby more fragile, and usually required more encouragement before they interacted physically

with the baby. None of the children asked to leave the unit and each child asked to come to see the

baby again.

An effort was made to explain the intravenous

lines, monitoring equipment, and respirators;

how-ever, most of the childrens’ questions involved the

baby: whether he would “grow more hair,” or would soon come home. Many children asked to feed the baby. One 4-year-old was concerned that his

brother would not fit through the small access ports

in the incubator cover and was relieved when the

incubator

side was opened. Surprisingly, the most

anxiety-provoking aspect of the visit was the

gown-ing of the child (a procedure which is probably

unnecessary). Some children seemed to fear a

gar-ment tied from behind. Hand scrubbing was

un-eventful. None of the child visitors interfered with

the monitoring or life-support equipment. Children

were distracted, but not visibly frightened, by the

various audible alarms sounding in the unit. A few

of the children were taken, at their request, to see other babies in the unit.

Parents’ comments about the visit were

uni-formly favorable. A number of children expressed an interest (to their parents) in returning to the

hospital the day following the visit. One mother

wrote that her child “wants to see the baby all of

the time.” Another child related his visiting

expe-rience to his nursery school class.

Although the nursing staff had reservations

about sibling visits prior to the start of the study,

informal discussions have shown them to be very receptive to visiting. They have not felt that the

children have disrupted the nursing routine and, in general, feel that this program enhances primary

nursing care to the patient and his family.

DISCUSSION

We hypothesized that visits by siblings to a NICU

would not be harmful and might be beneficial.

Potential risks of such visits include emotional

harm to the visiting child, disruption of the activity

of the NICU, and harm to the neonate through transmission of infectious disease or interference

with life-support equipment. Potential benefits

in-dude

enhanced emotional adjustment by the child

to the new member of his family, an understanding of the baby’s hospitalization, and an inclusion of the child in the family process.

Trause et al,3 using a behavioral questionnaire

similar to the one used in this study, analyzed the reactions ofyoung children to visiting their mothers following the birth of a sibling. The children who

visited were more responsive to their mothers and

siblings than the nonvisiting children. We did not

find signs of fear or anxiety in the children visiting

the NICU and could not demonstrate any emotional

harm. No child had a negative response to the visit

and all expressed a desire to return to see the

newborn sibling.

The children did not interfere with the function-ing of the unit or care of the neonates and we

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838

SIBLING VISITS IN NEONATAL INTENSIVE CARE UNIT

among the visited babies. Umphenour2 examined infection rates after sibling visits to a well-baby nursery, and found no increase in bacterial

coloni-zation among 182 visited infants. Williams and

Oliver5 and Barnett et al4 found that NICU visiting by parents and medical students did not change the levels of bacterial colonization or nosocomial infec-tions.

The benefits of visiting are harder to quantify. Nevertheless, children who visited used positive adjectives to describe the hospital, whereas nonvis-iting children gave fearful descriptions. Visiting might relieve the unpleasant fantasies that some children harbor regarding the appearance of their

infant

sibling. On the other hand, the negative impressions found in our control group may be the

result of their disappointment at being brought to the hospital, but excluded from visiting the sibling. It is also clear that visiting includes children in the family process. Siblings are able to share with their

parents both the joys and realities of a new birth. Following the sibling visits, we could not dem-onstrate adverse psychological consequences and our interviews suggested possible benefits to the child. Visiting might have ameliorated many of the

siblings’ malevolent fantasies regarding the baby

and reduced many of the mysteries attached to the birth and prolonged hospitalization of the neonate. This study also offered a chance to observe the first

contact between a child and his sibling. Many of

the children in our study first touched the infants with their fingertips and proceeded to stroking the infant’s trunk with the palm. Children frequently asked whether the infant’s eyes would open, and three children were found to assume the “en face” position. This is similar to maternal behavior on first contact with an infant as described by Klaus et al8 and might indicate that these forms of behav-ior are not only part of the process of maternal-infant bonding, but may occur when any family member encounters a small, fragile infant for the first time.

Clearly, the results ofthis preliminary study must be interpreted cautiously and cannot be applied to

all nurseries. A potential risk of visiting is the possibility that the sibling might be disturbed by

contact with other sick infants about whom

expla-nations are not fully explored. None of the infants

in this study died, but the effect of such a death, once the sibling has visited, is unknown. Few neo-natal deaths occur after the first week of life,

how-ever, so that appropriate screening would make this

event quite unusual. Our sample size was small,

which might have prevented us from documenting significant positive changes, but might also have prevented us from uncovering harmful effects.

Dif-ferences in the hospital and NICU environment, and the obstetric and neonatal population must be

taken into account. Most important, individual dif-ferences among children and the preferences of

their parents must be considered. Our data suggest, however, that sibling visits to a NICU are not likely

to be harmful and may, indeed, be beneficial to the child and his family.

ACKNOWLEDGMENTS

We thank Mary Anne Trause, PhD, for providing us

with the questionnaire used in her study; Drs Mark

Widome and John Dossett for their assistance; Mary Anne Trause, PhD, T. Berry Brazelton, MD, and

Mar-shall Klaus, MD, for review of the manuscript; and Dr

Marshall Jones for statistical advice.

REFERENCES

1. Editorial: Why not child visitors. Br Med J 1968;3:510 2. Umphenour JE: Bacterial colonization in neonates with

sibling visiting. JOGN Nurs 1980;9:73

3. Trause MA, Voos D, Rudd C, et al: Separation for childbirth: The effect on the sibling. Child Psychol Hum Deu 1981;12:32 4. Barnett C, Leiderman PH, Grobstein R, et al: Neonatal

separation: The maternal side of interactional deprivation.

Pediatrics 1970;45:197

5. Williams CPS, Oliver TK Jr: Nursery routines and staphy-lococcal colonization of newborn. Pediatrics 1969;44:640 6. Robertson J, Robertson J: Young children in brief

separa-tion. Psychoanal Study Child 1971;26:264

7. Freud A: Normality and Pathology in Childhood. New York, International Universities Press, 1966, p 273

8. Klaus MH, Kennell JH, Plumb N, et al: Human maternal behavior at the first contact with her young. Pediatrics

1970;46:187

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1983;71;835

Pediatrics

Fred Schwab, Brenda Tolbert, Stephen Bagnato and M. Jeffrey Maisels