The World Health Organization (WHO) defines preterm as "babies born alive before 37 weeks of pregnancy are completed".1 The organization estimates that globally, 15 million babies are born prematurely each year and that prematurity is the leading cause of death in children <5 years (1). Literature reporting the medical, educational and behavioural consequences and complications of prematurity is vast. Pravia and Benny (2020) synthesised literature on the long-term consequences of prematurity, reporting impact on the pulmonary system (vascular and alveolar development, increased asthma risk and decreased lung function), renal system (kidney disease and interrupted nephrogenesis) cardiovascular system (cardiac and vascular insults, dysfunction, hypertension, ischemic heart disease, heart failure), central nervous system (autism, mood disorders, intellectual disability) and the endocrine system (diabetes, obesity, metabolic syndrome, osteoporosis) (2). Wide-ranging economic consequences for healthcare systems in developed countries, families and wider society must be recognised. Family consequences include caring responsibilities, cost implications of health goods/interventions, nutritional needs, domestic work and home repairs (3).
Healy et al. (2021) (4) systematically reviewed reports of quality improvement for bronchopulmonary dysplasia (BPD) and identified BPD (formerly Chronic Lung Disease) as the most common morbidity in premature infants. A systematic review by Chaw et al. (2019) (5) concluded that the risk of severe respiratory syncytial virus (RSV) disease is substantially higher in infants with BPD, increasing the length of hospital stay and intensive care unit stay, duration of oxygen supplementation and mechanical ventilation compared to non-BPD infants. RSV is a seasonal common respiratory virus and a leading cause of morbidity and hospitalization in the paediatric population.(6) When comparing health resource utilisation among preterm and term infants hospitalised with RSV, a systematic review by Kenmoe et al. (2020) (7) concluded that irrespective of gestation, preterm infants have poorer outcomes and greater utilisation of health resources than term infants.
A Vietnamese cohort study by Do et al. (2020) (8) found that of the 193 preterm infants studied from birth-24 months corrected age, 47% were readmitted at least once in the first year and 22% in year two. All causes across the 2 years were due to respiratory infections (70%) followed by other infectious diseases (15%), echoing findings of prior studies in high-income countries. Recommendations included information provision for parents regarding illnesses and preventative practices to reduce readmission rates post-discharge (8). A one-year, Austrian, observational study by Steiner, Diesner and Voitl (2019) (9) aimed to research the differences in infection number and severity between 72 preterm and 71 full-term infants. Results showed significantly higher infection rates and severity in the preterm infants. Ear nose and throat and respiratory infections were most frequent with predominantly gastroenteritis and respiratory infections causing hospitalization. Recommendations included post-discharge comprehensive care and parent information about increased infection risk and infection prevention measures. Measures included family member vaccination, hand hygiene and avoidance of high-risk environments (9).
The WHO defines infection prevention and control (IPC) as a "scientific approach and practical solution designed to prevent harm caused by infection" (10). IPC draws upon the disciplines and evidence base of infectious diseases, epidemiology and healthcare system burdens (11). Health organizations including the WHO (12, 13) and European Centre for Disease Prevention and Control (14, 15) have produced technical guidance, campaigns and reports to prevent and manage infections such as COVID-19. Approaches to IPC in healthcare settings include strategies such as hand hygiene, wearing personal protective equipment, social distancing, patient movement considerations (one-way systems, improved signage), isolation areas, respiratory hygiene measures, increased environmental cleaning, consideration of ventilation such as opening windows, and offering remote consultations (16). IPC public guidance has included hand hygiene education, social distancing, isolation, testing, use of face masks and restriction of movement. Less clear information has been provided to parents regarding post-discharge prevention of infection in preterm infants. Prevention of nosocomial infection in the neonatal unit has been widely studied (17-19). Despite readmission risks, less is known about parent-implemented community measures.
Bracht, Bacchini and Paes (2021) (20) surveyed 583 Canadian participants regarding parental knowledge of RSV and other respiratory infections in preterm infants, concluding that parental knowledge of prophylaxis eligibility criteria is essential. A Neonatal Network piece highlighted the need for validation of parental concern regarding RSV, pre-discharge parental education, prevention strategies listed on a prepared letter for the family and prophylaxis importance (21).Vohr et al. (2017) (22) evaluated a transition-home program in the United States of America (USA) in relation to rehospitalization rates of preterm infants and concluded that preventative strategies must include the social, environmental and medical risk factors. Austin (2007) (23) described the home-health nurse role in RSV prevention in the USA including caregiver education strategies regarding hand hygiene, visitor limitation, day-care attendance, smoking, awareness of signs and symptoms and prophylactic immunisation. Stakeholder knowledge was sought by the protocol author KC. Service users and neonatal unit staff reported vague information and recommendations given at the clinician's discretion. Neonatal unit advice varied on frequency, content and the duration of measures recommended. Despite implications for mortality, disease burden and economic impacts, recommendations are not clearly or consistently presented. This review aims to assimilate existing heterogeneous literature sources and provide clarity regarding the characteristics of recommendations.
A preliminary search of MEDLINE (EBSCO host), Prospero, the Cochrane Database of Systematic Reviews and JBI Evidence Synthesis was conducted and no current or ongoing reviews on the topic were identified. This provides justification that there is appropriate evidence and significance to substantiate a scoping review on this topic. The review objective is to identify and map the characteristics (form, content, context and mode of delivery) of IPC measures and recommendations for parents of preterm infants discharged home to the community. The assimilation of evidence identified in this scoping review will inform future research recommendations. Further research conducted from these research recommendations will aim to subsequently influence policy and practice to mitigate the risk of infection and re-hospitalization.
Review questions
- What IPC measures and recommendations are available for parents/caregivers of preterm infants to during discharge or on discharge home to the community?
Sub Questions:
i) What is the range and extent of available evidence of knowledge and provision of IPC measures and recommendations for parents/caregivers of preterm infants during discharge or on discharge home to the community to mitigate the risk and incidence of infection and readmission to hospital?
ii) What are the characteristics (form, content, context and mode of delivery) of the IPC measures and recommendations?
Eligibility criteria
Participants
This review will consider evidence that includes individuals who are either the provider (for example but not limited to healthcare professionals, government/third-sector organization or peers) or recipient (parent/caregiver or preterm infant) of IPC measures and recommendations for preterm infants. A preterm infant will be defined as a baby born at < 37 weeks' gestation (1).
Concept
The core concept is parent/caregiver implemented IPC measures and recommendations and infection risk mitigation. Eligible sources must provide recommendations and or risk mitigation strategies, with the aim of prevention of community-acquired infection in the preterm child. Common IPC measures and recommendations include hand-hygiene, reduction in contact with others and environmental cleanliness. There will be no restriction on the background of the provider or the mode or form of delivery.
Context
This review is not limited to provision of recommendations from a specific healthcare setting or organization. The recommendations and measures to be included in this review may be recommended or provided prior to discharge of the preterm infant (for example during the discharge process, education classes or packages) or post-discharge, but with intended implementation of such recommendations to be conducted within the home or community environment by the parent/caregiver. Evidence will be excluded if it pertains to implementation of measures in a healthcare setting, by a healthcare professional, or if the implementation is not intended to be provided by the parent/caregiver of the infant. Sources are not limited by geographical location.
Types of Sources
This scoping review will have no limitation on the type of evidence source included and is inclusive of grey literature. Evidence sources may include but are not limited to primary research studies, opinion pieces, conference abstracts, pamphlets, websites, or blogs. The review will include sources of evidence from 1990-present day due to technological innovations in the field of neonatal care.(24) Sources must be either written in the English language or have a translation available. Sources excluded by language will be recorded within the audit trail and reported to uphold transparency.