Care opportunities for premature infants: home visits and telephone support*

Objective: to analyze opportunities for orientations to promote the care of premature infants during home visits and telephone support. Method: a qualitative study from the perspective of philosophical hermeneutics conducted with 18 mothers of premature infants discharged from hospital. Hospital contact and interviews were carried out, 15 and 45 days after discharge and at the infants’ six months of life, with data analysis by interpretation of meanings from 25 home visits and 56 telephone support contacts. Results: the following two thematic units emerged: Needs for contact and guidance: the place for home visits and opportunities for resolving doubts by telephone support, indicating aspects that suggest weakening child health, discontinuity in follow-up and vulnerability in specialized follow-ups. Home visits and telephone support favored the concern of health needs, doubts about basic care and problem solving, as ways to prevent damage and promote child health. Conclusion: home visits and telephone support emerge as collaborative practices of care and detection of latent conditions, which can be reduced or interrupted with prompt return of guidance, suggesting opportune strategies to increase follow-up, linkage and access to the health services.


Introduction
Premature births add up to approximately 15 million annually worldwide and are a public health problem because they are a risk factor for infant morbidity and mortality (1) . The literature points out that, after the hospitalization period, premature infants have health complications, and related to neurodevelopment in the first year of life and in the long term (1)(2) . Thus, home care is a challenge for families, with different health care needs (2) .
Access to health practices and continuity of care become essential, since premature infants require individual and singular care, due to the vulnerabilities and needs for continuous care to ensure health and development as well parental caregivers that require preparation and support to exercise care (3) . In this way, the performance of the health professionals is relevant for interventions with the families (4) . For this reason, they should use approaches to monitor premature infants in order to meet their needs and those of their families, considering that the mothers may be inexperienced.
Evidence shows the importance of approaches in family environments through Home Visits (HVs) and/or telephone support, increasing health, survival, and development (5) .
In child health, the HV is addressed to assess the mother-child interaction and child care (6) , to identify and intervene in vulnerable situations, to collaborate to improve the trajectories of women, children and families, with a positive impact on maternal and child health (7) , in the development of the bond, with increased breastfeeding rates, decreased smoking and mothers' return to work or school (8) . However, investments to structure the teams of primary care services and to organize health actions in households are limited in Brazil (9) .
Telephone support, reported as a way to improve health care access and efficiency, has good acceptability for families with children in vulnerable situations (10) ; however, it is a little explored practice in Brazil. The use of technology, such as mobile phones, is accessible to the population and services, in developed countries or not (11) .
In view of the relevance of the aforementioned strategies, the study aimed to analyze opportunities for guidance to promote the care of premature infant in HV and support through telephone.

Method
A qualitative study from the perspective of philosophical hermeneutics (12) , as a comprehensive-  (13) . There is no specific follow-up service for post-discharge pre-term infants, and this monitoring is carried out by the Center for Child Nutrition in the city, which has a pediatrician, a nurse and a nutritionist to care for premature or low weight infants.
Being a qualitative research, the search and inclusion of participants was completed when the results generated meanings to understand the phenomena in depth, richness and complexity (14) .  reinterpretation and explanation of the contents (15) without using data analysis software.  The HV and telephone support triggered the readiness to return to the guidelines, suggesting that they are opportune strategies to solve the problems identified by the mothers, as well as seeking health care when the child needs it.
Caring for premature infants at home requires careful assessment, considering family characteristics, emotional state of caregivers, stress levels, adaptation strategies, forms of home organization and the need for personal and professional support (16) . Several studies show that the combination of these factors results in support needs at home and strategies to meet involve integrated practices and services and assistance for urgencies and emergencies, including HV and telephone support carried out by qualified professionals (16)(17) .

Although regulated, home care in the Unified Health
System still has a character of complementary action in health networks and there is a deficit of home services on the national setting, when compared to other countries, such as Canada and the United States (9) .
The child's daily events at home were pointed out by the mothers as deserving attention. The literature addresses that premature babies sleep more, breastfeed slowly and often do not even wake up to breastfeed (18) , it is important to keep track of feeding times to avoid hypoglycemia, brain damage, coma, and death (19) .
Premature infants are smaller and are more likely to have hypotonia compared to full-term babies, and handling in a hygienic situation requires skills and freedom from fears about difficulties in body management and insecurity for the care of a small child (20) . In order for parental caregivers to face these new care situations, it is essential that the health team explain in detail each orientation before hospital discharge, in a welcoming manner, following the procedures in their execution and checking if, in fact, they are skilled and confident to carry them out (3)(4)20) . The experience of prematurity leads to contact with experiences that are beyond the knowledge and daily life of mothers and families (21) , which requires continuity of support.
The HV, considered an ancient care technology, brings favorable results and is important for the family, especially in vulnerable situations such as prematurity and those that recently come out of NICU (22) . The HV establishes a closer relation with the family environment, routines, culture and attitudes towards health care (17,22) .
These aspects show to be essential to ensure proper child development.
Premature children may have complex needs at home, with more difficulties for caregivers and possible errors in relation to food, medication and use of health equipment or services (22)(23) . The active presence of health professionals at the homes can anticipate the identification of errors and difficulties of caregivers, helping them to apply effective practices to enhance care for their children (23) .
In addition to the contribution of HV to the care of premature babies, telephone support has also been recognized as a way to improve access and efficiency in health care (24) , the similarity of the results of the present research that suggest the relevance of these strategies for the promotion of care for premature infants at home.
A number of research studies point out that the uses of new technologies need adaptations to increase health care, and some promising results have been recorded, both to follow the child's development and health conditions and to reduce the demand for hospital services (11,25) . to outline the way for the child to explore its potential and become a healthy and balanced adult (28) .
It is important to highlight the relevance of the to take care of their child at home and need an effective transition process (28)(29) .
On these occasions, having professional support allowed the mothers to express their concerns, and the dialog and guidelines drove possible solutions, suggesting new dimensions for safe practices for the development of premature infants at home. The experience of the meeting and the search for broadening horizons guided the understanding and interpretation in this study, mediated by the dialogical movement and its potential (12) . Thus, in order to implement home care networks for premature infants, articulated interventions are essential, with programs and protocols for followup and continuous monitoring, ensuring longitudinality of care (4,16,21) . Although the families received support from the Child Nutrition Center, it is not linked to the Family Health Strategy; therefore, they do not perform HVs, showing ruptures in the system that leave these mothers helpless in the home.
These results can contribute to direct and encourage the health professionals to support parental caregivers with a view to improving the care of premature babies at home and strengthening parenting skills, revitalizing the dialog and ensuring child and family-centered approaches, focused on attention to needs and singularities, promotion of healthy growth and development, and prevention of diseases and infant mortality.
As limitations, we must signal the centrality of maternal reports and follow-up in the first postdischarge months, considering that complications and/or difficulties to take care at home may arise beyond the child's six months of age, and new contacts by HVs or telephone support contacts will be important to support families and contribute to child development.

Conclusion
The opportunities for guidance in HV and telephone support proved to be relevant for promoting the care of