Repercussions of the Covid-19 pandemic in the care of premature infants

Altamira Pereira da Silva Reichert Anna Tereza Alves Guedes Anniely Rodrigues Soares Paloma Karen Holanda Brito Iolanda Carlli da Silva Bezerra Layla Caroline Lino da Silva Tayanne Kiev Carvalho Dias Nathanielly Cristina Carvalho de Brito Santos About the authors

Resumo

Objetivo

O estudo objetivou compreender as repercussões da pandemia da Covid-19 no cuidado de lactentes prematuros, na perspectiva de mães e profissionais de saúde.

Método

Foram realizadas entrevistas semiestruturadas nos meses de junho e julho de 2020, por meio de ligação telefônica, com 14 mães e quatro profissionais de saúde do serviço de follow-up de uma maternidade pública da Paraíba, Brasil.

Resultados

A partir da análise temática indutiva, os impactos da pandemia no cuidado ao lactente nascido prematuro, foram: sobrecarga e afastamento dos profissionais dos serviços de saúde, desativação temporária da unidade mãe canguru, descontinuidade da assistência ao prematuro, medo materno de expor a criança à Covid-19 e baixa condição socioeconômica. Foram elencadas estratégias de enfrentamento para o cuidado dos lactentes durante a pandemia, como: maior espaçamento das consultas, acompanhamento por meio telefônico e cumprimento das medidas de biossegurança.

Conclusão e implicações para a prática

A pandemia exigiu adaptações na assistência, tornando necessárias novas formas de cuidado a essas crianças, como exemplo, as consultas de acompanhamento remotas, a fim de garantir o seu direito à vida e saúde.

Palavras-chave:
Infecções por Coronavírus; Mães; Nascimento Prematuro; Pessoal de Saúde; Serviços de Saúde Materno-Infantil

Resumen

Objetivo

El estudio tuvo como objetivo comprender las repercusiones de la pandemia de Covid-19 en la atención de bebés prematuros, desde la perspectiva de las madres y los profesionales de la salud.

Método

Se realizaron entrevistas semiestructuradas en los meses de junio y julio de 2020, por medio de llamadas telefónicas, a 14 madres y cuatro profesionales de la salud del servicio de seguimiento de una maternidad pública en Paraíba, Brasil.

Resultados

A partir del análisis temático inductivo, los efectos de la pandemia en la atención de bebés prematuros fueron los siguientes: sobrecarga y distanciamiento de profesionales de los servicios de salud, inhabilitación temporal de la unidad Madre Canguro, discontinuidad de la atención al bebé prematuro, miedo materno a exponer al niño al Covid-19 y nivel socioeconómico bajo. Se enumeraron estrategias de afrontamiento para la atención infantil durante la pandemia, tales como: mayor intervalo entre consultas, seguimiento telefónico y cumplimiento de medidas de bioseguridad.

Conclusión e implicaciones para la práctic

a: La pandemia requirió adaptaciones en la atención, que hacen necesarias nuevas formas de atención para estos niños, como las consultas de monitoreo remoto, para garantizar su derecho a la vida y a la salud.

Palabras clave:
Infecciones por Coronavirus; Madres; Nacimiento Prematuro; Personal Sanitario; Servicios de Salud Materno-Infantil

Abstract

Objective

The study aimed at understanding the repercussions of the Covid-19 pandemic in the care of premature infants, from the perspective of mothers and health professionals.

Method

Semi-structured interviews were conducted in the months of June and July 2020, over the telephone, with 14 mothers and four health professionals from the follow-up service of a public maternity hospital in Paraíba, Brazil.

Results

From the inductive thematic analysis, the impacts of the pandemic on the care of premature infants were as follows: overload and distancing of health service professionals, temporary deactivation of the Kangaroo mother unit, discontinuity of care for the premature infant, maternal fear of exposing the child to Covid-19 and low socioeconomic status. Coping strategies for the care of infants during the pandemic were listed, such as: greater spacing between consultations, phone follow-up and compliance with biosafety measures.

Conclusion and implications for the practice

The pandemic required adaptations in care, which make new forms of care necessary for these children, such as remote follow-up consultations, in order to guarantee their right to life and health.

Keywords:
Coronavirus Infections; Health Personnel; Premature Birth; Mothers; Maternal-Child Health Services

INTRODUCTION

On January 30th, 2020, the World Health Organization (WHO) declared an international public health emergency as a result of the rapid spread of the Coronavirus Disease (Covid-19), caused by the new coronavirus (SARS-CoV-2), which appeared in December 2019 in the city of Wuhan, China11 World Health Organization. WHO Director-General’s opening remarks at the media briefing on COVID-19. Geneva: WHO; 2020 [citado 2020 outubro 12]. Disponível em: https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---28-september-2020
https://www.who.int/dg/speeches/detail/w...
. With the significant increase in infections by coronavirus worldwide, Covid-19 was characterized as a pandemic on March 11th, 202022 World Health Organization. Considerations for quarantine of individuals in the context of containment for coronavirus disease (COVID-19): interim guidance, 19 March 2020 [Internet]. Geneva: WHO; 2020 [citado 2020 outubro 12]. Disponível em: https://apps.who.int/iris/handle/10665/331497
https://apps.who.int/iris/handle/10665/3...
. Thus, the WHO recommended that the countries adopted public health measures such as quarantine, isolation and social distancing, in addition to running only essential services to reduce virus transmission and/or prevent the onset of the disease in new locations33 World Health Organization. Routine immunization services during the COVID-19 pandemic [Internet]. Geneva: WHO; 2020 [citado 2020 outubro 12]. Disponível em: https://apps.who.int/iris/handle/10665/331925
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Regarding the operation of health services, the Brazilian Ministry of Health (Ministério da Saúde, MS) recommended in early 2020 that the follow-up appointments, that is, consultations to monitor child growth and development, carried out by a multidisciplinary team in maternity outpatient clinics, were temporarily suspended, thus remaining under the responsibility of the Primary Health Care (PHC) teams44 Ministério da Saúde (BR). Nota técnica nº 6/2020 - COCAM/CGCIVI/DAPES/SAPS/MS. Atenção à Saúde do Recém-nascido no Contexto da Infecção do novo coronavírus (SARS-COV-2) [Internet]. Brasília: Ministério da Saúde; 2020 [citado 2020 outubro 12]. Disponível em: http://docs.bvsalud.org/biblioref/2020/04/1087595/notatecnicaneonatal30mar2020covid-19.pdf
http://docs.bvsalud.org/biblioref/2020/0...
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However, a number of studies in Family Health Units (FHUs) from Paraíba and Piauí found weaknesses in the surveillance of child development, at this point of the Health Care Network (Rede de Atenção à Saúde, RAS) with care actions performed in an unsatisfactory manner55 Vieira DS, Santos NCCB, Nascimento JA, Collet N, Toso BRGO, Reichert APS. A prática do enfermeiro na consulta de puericultura na Estratégia Saúde da Família. Texto Contexto Enferm. 2018;27(4):1-10. http://dx.doi.org/10.1590/0104-07072018004890017.
http://dx.doi.org/10.1590/0104-070720180...
,66 Oliveira FFS, Oliveira ASS, Lima LHO, Marques MB, Felipe GF, Sena IVO. Child care consultations held by nurses within the Family health strategy. Rev Rene. 2013; [citado 2020 outubro 12];14(4):694-703. Disponível em: http://www.periodicos.ufc.br/rene/article/view/3526
http://www.periodicos.ufc.br/rene/articl...
. In addition, the most worrying aspect is that, due to the pandemic, childcare consultations were maintained only for high-risk children, resulting in discontinuity of care77 Paraná. Governo do Estado. Secretária de Saúde do Estado do Paraná. Coronavírus (COVID-19) - Nota orientativa nº 29/2020 - Atendimento em puericultura. Curitiba: Secretária de Saúde do Estado do Paraná; 2020 [citado 2020 outubro 12]. Disponível em: https://www.saude.pr.gov.br/sites/default/arquivos_restritos/files/documento/2020-06/no_29_atendimento_em_puericultura.pdf
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The WHO points out that the likelihood of a premature child to survive, grow and develop in full depends, among other factors, on timely access to health care at birth and throughout its growth and development88 World Health Organization. Survive and thrive: transforming care for every small and sick newborn [Internet]. Geneva: WHO; 2019 [citado 2020 outubro 12]. Disponível em: https://www.who.int/maternal_child_adolescent/documents/care-small-sick-newborns-survive-thrive/en/
https://www.who.int/maternal_child_adole...
. Therefore, it is fundamental to monitor premature children's health and the existence of an articulated and coordinated health system88 World Health Organization. Survive and thrive: transforming care for every small and sick newborn [Internet]. Geneva: WHO; 2019 [citado 2020 outubro 12]. Disponível em: https://www.who.int/maternal_child_adolescent/documents/care-small-sick-newborns-survive-thrive/en/
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Regarding children who are born prematurely, given the infection by the SARS-CoV-2 virus, concern for them is greater, due to the fragility of the immune system, still immature, which requires priority care, since the infection may develop severe forms of the disease, requiring absolute support of the health system99 Wang L, Shi Y, Xiao T, Fu J, Feng X, Mu D et al. Chinese expert consensus on the perinatal and neonatal management for the prevention and control of the 2019 novel coronavirus infection (First edition). Ann Transl Med. 2020;8(3):1-8. http://dx.doi.org/10.21037/atm.2020.02.20.
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The Covid-19 pandemic brought about countless repercussions for the assistance provided to children that are born prematurely, as noted in national and international studies that identified interruption in the monitoring of premature infants after hospital discharge due to the momentary interruption of the follow-up services, with consequences for the discontinuation of the health care provided to that population1010 Silva RMM, Pancieri L, Zilly A, Spohr FA, Fonseca LMM, Mello DF. Follow-up care for premature children: the repercussions of the COVID-19 pandemic. Rev Lat Am Enfermagem. 2021;29:e3414. http://dx.doi.org/10.1590/1518-8345.4759.3414. PMid:33852686.
http://dx.doi.org/10.1590/1518-8345.4759...
,1111 Li L, Li Z, Wan W, Li J, Zhang Y, Wang C et al. Management of follow-up with preterm infants during the outbreak in China. Front Pediatr. 2021;9:637275. http://dx.doi.org/10.3389/fped.2021.637275. PMid:33996687.
http://dx.doi.org/10.3389/fped.2021.6372...
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Considering the vulnerability of premature infants and the temporary suspension of the follow-up consultations given the pandemic, as well as the isolation measures that hampered monitoring of this group in the state of Paraíba, the study is justified by the relevance of reflecting on child monitoring in the face of the Covid-19 pandemic, in view of the need for continuous care to the children, especially premature, with more vigilant attention in the first year of life.

Therefore, seeking to understand the impact of the Covid-19 pandemic on the care of premature infants from the perspective of mothers and health professionals is of fundamental relevance for the continuity of the comprehensive care provided to this group. Thus, this study aims at understanding the repercussions of the Covid-19 pandemic on the care of premature infants, from the perspective of mothers and health professionals.

METHOD

This is a descriptive and exploratory research study with a qualitative approach, carried out at an outpatient follow-up clinic with patients discharged from the Kangaroo mother method in a public maternity hospital from a municipality of Paraíba, Brazil. The study included 14 mothers of premature infants and four health professionals, who monitored the children at the aforementioned outpatient clinic.

The following inclusion criteria were adopted for the mothers: mothers of infants discharged from the Kangaroo mother unit of the aforementioned maternity hospital, whose children had their follow-up monitoring interrupted or restricted due to the Covid-19 pandemic, being over 18 years old, and having a cell phone. The following criterion was adopted for the health professionals: performing monitoring of the growth and development of premature infants in the follow-up service, before the Covid-19 pandemic, since we believe that they would have a better perspective about the impact of interrupting the consultations for some children.

A total of 56 phone calls were made to the mothers of discharged infants; of these, 13 did not meet the inclusion criteria, five refused to take part in the study, and it was not possible to establish contact with 24; thus, 14 mothers of premature-born infants took part in the survey.

This study had four interviewers with experience in the collection of qualitative data. They were previously trained by the main researcher, through remote meetings. The pilot test performed by all the interviewers aimed at verifying consistency and understanding of the guiding questions, being validated by a professor with expertise in the subject matter and included in the interviews.

Data collection took place during June and July 2020, using the semi-structured interview technique, self-recorded in electronic media, and via phone calls, given social isolation during the Covid-19 pandemic. The mothers were recruited by convenience from the contact phone number available in the medical records of the children registered in the follow-up service.

Initially, the researchers contacted the study participants by means of phone calls in order to have a first approximation to them, present the objectives and invite them to take part in the research. The scheduling of the interviews with the mothers occurred according to availability and acceptance so that, in case of refusal, the following mother in the list was contacted. As for the health professionals, recruitment was from a list provided by the manager of the aforementioned health service, containing the respective phone numbers.

The interview script contained two parts: the first with sociodemographic information and the second with guiding questions. The interviews with the mothers were guided by the following questions: How is the monitoring of your child's taking place in the Covid-19 pandemic? Have you perceived any change in the assistance provided? If so, what do you think of these changes in relation to the care provided to your child? As for the health professionals, the questions were the following: How is the monitoring of the growth and development of children that were born prematurely taking place in the Covid-19 pandemic? What is your perception about the changes occurred in child care in this service, due to Covid-19? The interviews lasted a mean of 20 minutes and the empirical material was transcribed in full; however, there was no devolution to the research participants.

The study sought to cover all the actors involved in the monitoring of the growth and development of these children. To close collection of the mothers' statements, the sufficiency criterion was used, when it was possible to reflect on the multiple dimensions of the study object1212 Minayo MCS. Amostragem e saturação em pesquisa qualitativa: consensos e controvérsias. Rev Pesqui Qual (Online). [Internet]. 2017; [citado 2020 outubro 12];5 (7):1-12. Disponível em: https://editora.sepq.org.br/index.php/rpq/article/view/82/59
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, totaling 14 interviews. It is noteworthy that, of the five professionals working in the follow-up outpatient clinic, only one did not participate in the study, given that she joined the service during the pandemic, when some children's consultations had already been interrupted.

To analyze the empirical data, the inductive thematic analysis technique was used,1313 Braun V, Clarke V. Using thematic analysis in psicology. Qual Res Psychol. 2006;3(2):77-101. http://dx.doi.org/10.1191/1478088706qp063oa.
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which is structured in six phases: Familiarity with the theme, which requires prior and active reading of the empirical material; Generation of initial codes to identify similar sets; Search for topics in order to select different codes for potential themes; Review of the topics, which occurs by reading all the data extracts that comprise each theme and visualizing the relationship among them; Definition of the topics to identify them; and Final textual production, with treatment and interpretation of the results in the light of the literature concerning the subject matter.

The study, linked to a project funded by the Foundation for Research Support of the State of Paraíba (Fundação de Apoio à Pesquisa do Estado da Paraíba, FAPESQ), met the ethical principles set forth in Resolution 466/12 of the National Health Council (Conselho Nacional de Saúde, CNS), with approval by the Research Ethics Committee of the Health Sciences Center, Federal University of Paraíba (Universidade Federal da Paraíba, UFPB), under CAAE: 31353220.3.0000.5188.

All the study participants were handed in the Free and Informed Consent Form, as well as the guarantee of anonymity, through coding of the statements with the letter “M”, referring to Mother, and “P” for the professionals, both followed by the numbering corresponding to the order in which the interviews were conducted, namely: M1, M2 [...]; P1, P2 [...]. It is noteworthy that each agreement was recorded verbally, after reading the FICF before initiating the phone interviews.

It is noteworthy that, in this study, the Consolidated Reporting Criteria for Qualitative Research (COREQ) were used as a support tool in relation to the methods of qualitative studies1414 Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349-57. http://dx.doi.org/10.1093/intqhc/mzm042. PMid:17872937.
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RESULTS

Of the 18 study participants, 14 were mothers of premature infants, and four were health professionals working in the follow-up service. The mothers were aged between 23 and 38 years old; among them, three had less than eight years of study, and 11 had eight years or more. As for family income, nine earned up to a minimum wage, and five earned more than one minimum wage. In addition, nine were in stable unions, four were single and one was a widow.

In relation to the health professionals, all were female, as follows: one nurse, one speech therapist, one nursing technician and one physician, aged between 38 and 57 years old. With regard to marital status, three were married and one divorced. As for the working time in maternal-child care, two had less than 10 years, and two had more than 20 years.

Two themes were elaborated from the empirical analysis: Theme I: Repercussions of Covid-19 on the assistance provided to the premature infant; Theme II: Coping strategies for the organization of the outpatient care provided to premature infants in the Covid-19 pandemic, as shown in Figure 1.

Figure 1
Final thematic map containing the two main themes. João Pessoa, Paraíba, Brazil, 2020.

Theme I: Repercussions of the Covid-19 pandemic on the assistance provided to the premature infant

The pandemic context reflected in the assistance offered to premature infants in different points of the Health Care Network. In tertiary care, it is revealed that, with the pandemic and due to the distancing of some health professionals considered a risk group, there was overload in those who continued carrying out consultations in the follow-up service, despite the reduction in the number of children to be cared for:

Many times, I made an active search, calling, wanting to know why they (the children) didn't come, whatever, I made such service, but, as our demand increased a lot, I end up having no time for that. In this pandemic period, it seems that my work has increased. No patient, but it's harder now (P1).

Our big problem is the professionals who were distanced. In my case, a colleague who worked with me had a baby and was distanced from the service before birth and now is still on leave, and I have to be covering part her duties too (P2).

In addition, another repercussion related to the Covid-19 pandemic on the assistance provided to premature infants was the temporary deactivation of the Kangaroo Intermediate Care Unit (Unidade de Cuidados Intermediários Canguru, UCINCa), a fundamental sector for the survival of these children, further increasing their vulnerability and the need for comprehensive and continued care.

At the time of the pandemic, it's a little different, because the service of the kangaroo method has been deactivated and the patients are discharged directly from the ICU (Intensive Care Unit) to their homes (P2).

In turn, when asked about monitoring of the premature infants in another point of the Health Care Network, such as PHC, the mothers evidence that care for premature children has also been reduced or even interrupted.

There now everything stopped, not even in Institution X (institution that assists disabled people) even there, there is nothing more. No, in the local center (FHU) here they aren't offering services either, so for consultation, they're only treating urgencies or giving some prescription (M17).

The local center (FHU) is only treating urgencies. Only if you come with a Covid-19 case. Even the vaccines were late, they didn't want to apply, then I went, I spoke there, then they applied her vaccines and updated the schedule (M7).

It is observed that, in addition to the changes in the health care services during the pandemic, there was absenteeism of some children who should continue being monitored because of maternal fear of exposing the child to the risk of contracting the disease, and the precarious family financial condition also affected the assistance provided in the follow-up service, according to excerpts from the mothers' and health professionals' statements.

We're no longer being monitored, because we were afraid to travel, we were very afraid, then we talked to the doctor, who called to make an appointment, but we didn't want to make it because we were afraid, because the baby can't wear a mask and we can, but they can't, then there's the risk of the baby getting contaminated (M2).

She (the professional) told me, when all this improved a little, to return, but then the situation worsened, so I didn't go any more, I was afraid... Why lying about that! (M1).

[...] In addition to that, the mothers are too afraid to go out of their house, take public transportation and even arrive at the hospital (P2).

The mothers can't afford it, they value the service, they want to come, but they can't, no way, then they keep failing to come, delaying. That really undermines child monitoring (P1).

Theme II: Coping strategies for the organization of the outpatient care provided to premature infants in the Covid-19 pandemic

The emergence of Covid-19 required health services and families to implement coping strategies capable of reducing the impacts of the pandemic on the health of premature infants. Under such perspective, the follow-up service, as a way to avoid contagion, adhered to several measures, the following among them: reducing the number of children treated and increased spacing between the monitoring consultations in the case of those that were indispensable.

Before they were going with 8, 15 days (consultation), when it was normal, but now, with this pandemic, it's taking longer (P3).

They're seeing fewer patients, taking all the precautions, they call the patients one by one, and that's all (M21).

The issue of the number (of appointments) per day is also to prevent agglomeration, we're maintaining a mean of 7-8 patients a day, before this it was a mean of 12 to 15. We reduced because of the agglomeration. We're requesting the use of masks even for those who are in the waiting room, and the seats are marked with the chairs that are available and not available for us to keep the distancing (P4).

Faced with the limitations of personal appointments for the premature infant in the follow-up outpatient clinic during the pandemic, in order to meet the needs of the children and of their family members, the phone service was implemented as a way for not causing a total interruption in the monitoring of these children.

He's not having appointments there (follow-up), in-person, but he's being monitored through the cell phone, because upon any doubt, any little thing that he feels, I call, and there the doctor sees him, and she informs me everything through the cell phone [...] The doctor clarifies all my doubts when I call her, she explains me everything, it seems that I'm there with her. In this regard, it's the same thing for me (M9).

We always keep in touch through WhatsApp, by phone and we're always having news about the babies, you know? When they don't come for an appointment, they send some question, and we're always answering and trying not to lose that bond, which is very important (P2).

When the mother has some doubt, she's with little milk, then I ask her to make a video to see how the baby is sucking, and if such is the case, I guide her to some better position. Sometimes, they send a video, and you can make a comparison with the previous video they sent. So, you'll be monitoring the development of that child. We don't want them to distance from here (P4).

Despite the adversities arising from the pandemic scenario, there was a change in the organization of the outpatient care provided to premature infants, with more caution with regard to the hygiene measures to prevent the spread of Covid-19, both by the health professionals and by the mothers.

The parents have to spend more time inside the house and, consequently, are paying more attention to the child too. Today, they're more afraid, they're taking better care of the child. I see better hygiene with the child and the mother herself, they're taking better care of themselves (P4).

My routine has changed in relation to the PPE (Personal Protective Equipment), because before we didn't use them as much as today (P4).

We're taking all the care measures as recommended by surveillance [...] if we had many care measures before, today it is doubled; care is even greater in the sense of always being protected, whenever doing some procedure, hand hygiene and wearing the PPE; never stop using, mainly, that's it (P1).

[...] I began to double the care measures in relation to her. An example: before I went out to the street, to take her to vaccinate, when we came back, if she wasn't dirty, I didn't bathe her, but not today, when she's going to be vaccinated, when she's back, we bath her. We also have a tiny mask that we made for her here at home. In the same way, as in my case, I take off all my clothes, put them to wash and then I take a shower (M6).

DISCUSSION

The crisis resulting from the Covid-19 pandemic caused countless changes, both in the home environment and in the health services that provide care to the premature infants. One of the repercussions on the assistance offered by the tertiary-level care services was the overload of the professionals working in follow-up, due to staff downsizing, as some professionals that were working there were distanced for being considered risk groups for the disease. Thus, both health professionals and the families of premature infants needed to reinvent themselves not to impair the care provided to the children.

Several changes in the work processes and in health care were necessary, such as the following: introduction of new treatment protocols; use of PPE, not previously used in several contexts; suspension of some appointments; distancing or relocation of workers considered risk groups, among other aspects that hinder health care1515 Adams JG, Walls RM. Supporting the health care workforce during the COVID-19 global epidemic. JAMA. 2020;323(15):1439-40. http://dx.doi.org/10.1001/jama.2020.3972. PMid:32163102.
http://dx.doi.org/10.1001/jama.2020.3972...
,1616 Teixeira CFDS, Soares CM, Souza EA, Lisboa ES, Pinto ICDM, Andrade LRD et al. A saúde dos profissionais de saúde no enfrentamento da pandemia de Covid-19. Cien Saude Colet. 2020;25(9):3465-74. http://dx.doi.org/10.1590/1413-81232020259.19562020. PMid:32876270.
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and cause physical and emotional overload in the professionals.

In this directive, the excerpts from the statements reveal that the pandemic scenario has considerably modified the assistance provided to the children and the health professionals' working environment. However, these changes were necessary, in view of the health work process being dynamic, being transformed from the actions of the workers who, through their operating knowledge and of technological models, modify their work contexts, in order to meet social purposes1717 Peduzzi M, Anselmi ML. O processo de trabalho de enfermagem: a cisão entre planejamento e execução do cuidado. Rev Bras Enferm. 2002;55(4):392-8. http://dx.doi.org/10.5935/0034-7167.20020086. PMid:12728804.
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Therefore, with the pandemic, stress arose due to the health professionals' increased work demands and to the effects of this situation, such as the growing fear and insecurity in relation to the high contagion risk, which causes distancing from the services and, in turn, discontinuity of the care provided1818 Almaghrabi RH, Alfaraidi HA, Al Hebshi WA, Albaadani MM. Healthcare workers experience in dealing with Coronavirus (COVID-19) pandemic. Saudi Med J. 2020;41(6):657-60. http://dx.doi.org/10.15537/smj.2020.6.25101. PMid:32518935.
http://dx.doi.org/10.15537/smj.2020.6.25...
,1919 Góes FGB, Silva ACSS, Santos AST, Pereira-Ávila FMV, Silva LJ, Silva LF et al. Challenges faced by pediatric nursing workers in the face of the COVID-19 pandemic. Rev Lat Am Enfermagem. 2020;28:e3367. http://dx.doi.org/10.1590/1518-8345.4550.3367. PMid:32901774.
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. This is consistent with the statements made by the participants in this study, who report increased workload due to staffing shortages.

It is important to highlight that, although Covid-19 has affected few Newborns (NBs), the disease has caused major changes in the humanized care model for the Preterm Newborn (PNB) and/or for those with low birth weight, as evidenced in the results of this study, which highlight the temporary interruption of the second stage of the Kangaroo Method (KM). This discontinuity of the method is contrary to the current MS guidelines, which recommend that the UCINCas should not be closed or restricted during the pandemic, since the purpose of the KM is to reduce the child mortality rates2020 Ministério da Saúde (BR). Nota técnica nº 6/2020 COCAM/CGCIVI/DAPES/SAPS/MS - Atenção à Saúde do Recém-nascido no Contexto da Infecção do novo coronavírus (SARS-COV-2) [Internet]. Brasília: Ministério da Saúde; 2020 [citado 2020 outubro 12]. Disponível em: https://www.unasus.gov.br/especial/covid19/pdf/97
https://www.unasus.gov.br/especial/covid...
.

The Kangaroo mother strategy should occur in three stages: the first is developed during hospitalization of the premature newborns and/or of those with low birth weight in the Neonatal Intensive Care Unit or in the Conventional Neonatal Intermediate Care Unit; in the second, the babies remain at all moments with their mothers, in the kangaroo position in the UCINCa; and the third stage is at home, with follow-up shared between the outpatient clinic unit of the maternity hospital where the baby was born and the Basic Health Unit, until the NB weighs 2,500 g2121 Ministério da Saúde (BR). Método Canguru: manual da terceira etapa do Método Canguru na Atenção Básica [Internet]. Brasília: Ministério da Saúde; 2018 [citado 2020 outubro 12]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/manual_terceira_etapa_metodo_canguru.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...
.

Therefore, interruption of the KM can become a risk factor for the preterm newborns and/or for those with low birth weight, since absence of the care proposed by the method and lack of comprehensive and qualified assistance can cause serious harms and disabilities to these children2222 Ministério da Saúde (BR). Atenção humanizada ao recém-nascido: Método Canguru: manual técnico [Internet]. Brasília: Ministério da Saúde; 2017 [citado 2020 outubro 12]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/atencao_humanizada_metodo_canguru_manual_3ed.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...
.

In this research, follow-up of the premature infants was interrupted, causing insecurity for the family in the provision of care. This reality can exert an effect on the children's neuropsychomotor development, as well as on their quality of life, as this interruption hinders the monitoring of their health, with future repercussions, given that the children's first years of life are essential for their full development. This is due to brain plasticity, when new experiences underwent by the babies favor the formation of other brain connections. Thus, this period corresponds to the best opportunity to promote cognitive, physical, health and educational development, as well as to positively shape the children's future2323 Sparling J, Meunier K. Abecedarian: an early childhood education approach that has a rich history and a vibrant present. Int J Early Child. 2019;51(2):207-16. http://dx.doi.org/10.1007/s13158-019-00247-2.
http://dx.doi.org/10.1007/s13158-019-002...
,2424 Mushtaq A, Kazi F. The case for early child development programmes. Lancet Child Adolesc Health. 2019;3(12):851. http://dx.doi.org/10.1016/S2352-4642(19)30298-6.
http://dx.doi.org/10.1016/S2352-4642(19)...
.

The excerpts from the the study participants' statements also reveal that, in order to guarantee follow-up of the premature newborn, the assistance offered needed to be modified with measures intended to prevent contagion, requiring the professionals to use strategies capable of reducing the impacts of the pandemic on the health of the premature newborn, such as increasing spacing between the appointments and reducing the number of outpatient appointments. However, this new organization of work for care and assistance can contribute to a significant loss of the bond or even to the disruption of the professional-patient relationship2525 Sachett JAG. Adaptação para o atendimento profissional de saúde em tempos de COVID-19: contribuições da telessaúde para o “novo normal”. J Health NPEPS. 2020;5(2):11-5. http://dx.doi.org/10.30681/252610104877.
http://dx.doi.org/10.30681/252610104877...
.

Thus, to face the pandemic, re-adaptations in the routine of the professionals and the health services are necessary, incorporating strategies so that the service works, including new ways of remote care, with the use of information and communication technologies such as social media and cell phones for teleconsultations2626 Medina MG, Giovanella L, Bousquat A, Mendonça MHM, Aquino R, Comitê Gestor da Rede de Pesquisa em Atenção Primária à Saúde da Abrasco. Atenção primária à saúde em tempos de COVID-19: o que fazer? Cad Saude Publica. 2020;36(8):e00149720. http://dx.doi.org/10.1590/0102-311x00149720. PMid:32813791.
http://dx.doi.org/10.1590/0102-311x00149...
.

This is a viable strategy to ensure care for premature infants and to meet the needs of the child and their family members, since phone support in a pandemic scenario can be a viable alternative to avoid discontinuing the monitoring of these children. However, it is necessary to discern the situations that require contact with the mother-child binomial, which are hardly replaced by online consultation2727 Sarti TD, Lazaríni WS, Fontenelle LF, Almeida APS. Qual o papel da Atenção Primária à Saúde diante da pandemia provocada pela COVID-19? Epidemiol Serv Saude. 2020;29(2):e2020166. http://dx.doi.org/10.5123/S1679-49742020000200024. PMid:32348404.
http://dx.doi.org/10.5123/S1679-49742020...
.

In addition, phone monitoring favors the apprehension of health needs and clarification of the mothers' doubts about basic and daily care for the child2828 Silva RMM, Zilly A, Nonose ERS, Fonseca LMM, Mello DF. Care opportunities for premature infants: home visits and telephone support. Rev Lat Am Enfermagem. 2020;28:e3308. http://dx.doi.org/10.1590/1518-8345.3520.3308. PMid:32609266.
http://dx.doi.org/10.1590/1518-8345.3520...
, as evidenced by one of the study participants when she mentioned that monitoring and care continuity over the phone were able to solve their children's health problems.

Another repercussion of the pandemic scenario, pointed out in this study, was impairment of consultations with children at the FHUs, due to the reduction or even interruption of the child's monitoring in childcare. A study carried out in pediatric outpatient clinics in Italy evidenced that there was a 98.2% reduction in the consultations during the pandemic period2929 Bechini A, Garamella G, Giammarco B, Zanella B, Flori V, Bonanni P et al. Paediatric activities and adherence to vaccinations during the COVID-19 epidemic period in Tuscany, Italy: a survey of paediatricians. J Prev Med Hyg. 2020;61(2):E125-9. http://dx.doi.org/10.15167/2421-4248/jpmh2020.61.2.1626. PMid:32802994.
http://dx.doi.org/10.15167/2421-4248/jpm...
.

This interruption is worrying, given that follow-up for children's health enables early detection of possible health problems and deficits in childhood, from surveillance of child development. This comprises a soft technology in health, allowing to intervene in health problems in a timely manner, minimizing the risks and preventing the occurrence of morbidity and mortality55 Vieira DS, Santos NCCB, Nascimento JA, Collet N, Toso BRGO, Reichert APS. A prática do enfermeiro na consulta de puericultura na Estratégia Saúde da Família. Texto Contexto Enferm. 2018;27(4):1-10. http://dx.doi.org/10.1590/0104-07072018004890017.
http://dx.doi.org/10.1590/0104-070720180...
.

Consequent to this scenario, the routine immunization coverage was also impacted in the health services, with a significant reduction in the demand and supply of vaccines, also found in research studies in the United States, which point to a decline in routine immunization3030 Santoli JM, Lindley MC, DeSilva MB, Kharbanda EO, Daley MF, Galloway L et al. Effects of the COVID-19 pandemic on routine pediatric vaccine ordering and administration – United States, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(19):591-3. http://dx.doi.org/10.15585/mmwr.mm6919e2. PMid:32407298.
http://dx.doi.org/10.15585/mmwr.mm6919e2...
,3131 Vogt TM, Zhang F, Banks M, Black C, Arthur B, Kang Y et al. Provision of Pediatric Immunization Services During the COVID-19 Pandemic: an Assessment of Capacity Among Pediatric Immunization Providers Participating in the Vaccines for Children Program — United States, May 2020. MMWR Surveill Summ. 2020;69(27):859-63. http://dx.doi.org/10.15585/mmwr.mm6927a2. PMid:32644980.
http://dx.doi.org/10.15585/mmwr.mm6927a2...
. This is consistent with the findings of this study, since the reports unveil difficulties updating the child's immunization schedule.

It is worth noting that, in a pandemic situation, interruption of basic care, such as vaccination, is a potential risk for even more serious crises in health, with other disease outbreaks. Thus, together with UNICEF and the Brazilian Society of Pediatrics and Immunization, the WHO recommended the reorganization of the services to continue the operation of the vaccines rooms and to safely maintain the routine, with the need to prioritize children under five years old, pregnant women and risk groups through in-service or external appointments, provided that the preventive measures for the new coronavirus are complied with33 World Health Organization. Routine immunization services during the COVID-19 pandemic [Internet]. Geneva: WHO; 2020 [citado 2020 outubro 12]. Disponível em: https://apps.who.int/iris/handle/10665/331925
https://apps.who.int/iris/handle/10665/3...
,3232 Sociedade Brasileira de Pediatria. Pandemia da Covid-19 - O que muda na rotina das Imunizações [Internet]. 2020. [citado 2021 maio 4]. Disponível em: https://portaldeboaspraticas.iff.fiocruz.br/biblioteca/pandemia-da-covid-19-o-que-muda-na-rotina-das-imunizacoes/
https://portaldeboaspraticas.iff.fiocruz...
.

Despite some weaknesses in the performance of the Family Health Strategy teams, this is the most suitable and efficient model to support the populations in a social isolation situation, as it is necessary to maintain people's contact and bond with the professionals that are responsible for health care2626 Medina MG, Giovanella L, Bousquat A, Mendonça MHM, Aquino R, Comitê Gestor da Rede de Pesquisa em Atenção Primária à Saúde da Abrasco. Atenção primária à saúde em tempos de COVID-19: o que fazer? Cad Saude Publica. 2020;36(8):e00149720. http://dx.doi.org/10.1590/0102-311x00149720. PMid:32813791.
http://dx.doi.org/10.1590/0102-311x00149...
.

With regard to the assistance provided to the premature infant, the findings of this study point out the influence of factors such as fear of the mothers in exposing the children to the risk of infection by the SARS-CoV-2 virus, especially in the commute to the health services, given the need to use public transportation, a situation that resulted in discontinuity of the assistance provided to the children. A similar fact was observed in a research study conducted with relatives of Italian children with special needs, which evidenced that, due to fear of infection by the new coronavirus, even in cases of illness, the family avoided taking them to the health services, which resulted in deterioration of the clinical condition in half of the sample, and in the death of four children3333 Lazzerini M, Barbi E, Apicella A, Marchetti F, Cardinale F, Trobia G. Delayed access or provision of care in Italy resulting from fear of Covid-19. Lancet Child Adolesc Health. 2020;4(5):e10-1. http://dx.doi.org/10.1016/S2352-4642(20)30108-5. PMid:32278365.
http://dx.doi.org/10.1016/S2352-4642(20)...
.

Also in relation to the coping strategies for the assistance provided to premature infants, the intensification of hygiene measures and use of PPE by the health staff stand out. A number of national studies reveal that the professionals became more aware on the hand hygiene measures, disinfection with 70% alcohol, and use of personal protective equipment66 Oliveira FFS, Oliveira ASS, Lima LHO, Marques MB, Felipe GF, Sena IVO. Child care consultations held by nurses within the Family health strategy. Rev Rene. 2013; [citado 2020 outubro 12];14(4):694-703. Disponível em: http://www.periodicos.ufc.br/rene/article/view/3526
http://www.periodicos.ufc.br/rene/articl...
,3434 Rodrigo JAP, Stelmatchuk AM, Lacerda MR, Galvão CM. Medidas de contenção à Covid-19 adotadas em serviço de transplante de medula óssea. Rev Bras Enferm. 2020;73(supl 2):e20200476. http://dx.doi.org/10.1590/0034-7167-2020-0476.
http://dx.doi.org/10.1590/0034-7167-2020...
.

The change in the care measures was not exclusive to the health professionals, as the families and the community had to adopt new hygiene and social isolation habits. Among the measures cited by the mothers, who became more cautious with their children, are the following: increased hand hygiene with soap and water, using 70% alcohol, and taking a shower upon returning home. The results are consistent with an international research study conducted in Jordan, where it was evidenced that the families avoided going out of their homes, frequently washed their hands and their children's, and also used to clean and disinfect the surfaces with which the child comes into contact, as preventive measures against the new coronavirus3535 Abuhammad S. Parents’ knowledge and atitude towards COVID-19 in children: a Jordanian study. Int J Clin Pract. 2021 fev;75(2):e13671. http://dx.doi.org/10.1111/ijcp.13671. PMid:32780560.
http://dx.doi.org/10.1111/ijcp.13671...
.

It is to be noted that the most vulnerable communities often cannot comply with these hygiene and social isolation measures, as many families have deficient access to basic sanitation and to drinking water, as well as they fail to maintain isolation given the family and social context3636 Souza MN. Desigualdade e seletividade social das medidas de contenção da Covid-19 na periferia de Curitiba. Guaju. 2020;6(1):131-46. http://dx.doi.org/10.5380/guaju.v6i1.73654.
http://dx.doi.org/10.5380/guaju.v6i1.736...
and cannot also afford to buy 70% alcohol gel. Such reality requires a differentiated and expanded perspective from the health professionals about the context in which the child and family live, so as to plan coping strategies for Covid-19 and care continuity.

Given the above, the importance of using strategies to adapt the health services and actions to the changing social contexts in which children and their families are inserted is highlighted, so as to ensure continuity of the bond with the professionals and to promote comprehensive and longitudinal assistance to this group.

CONCLUSION AND IMPLICATIONS FOR THE PRACTICE

The repercussions of the Covid-19 pandemic on the care of premature infants are related professional overload, limited monitoring of the premature infant in the Health Care Network, maternal fear of exposing the child to the disease, and decline in the families' socio-economic conditions. As coping strategies for care, given the pandemic in the follow-up sector, an increase was observed in the spacing between the consultations, monitoring of the child's health over the phone, and expansion of hygiene measures and precautions.

The new context, challenging and full of uncertainties, imposed adaptations on the family members and the professionals in order to ensure qualified and effective care to the premature infant. In addition, the need to reorganize the services and the health professionals' work process required a more dynamic performance given the demands of premature children in pandemic times.

The findings of this study bring about the following as implications for the professional practice: targeting at care and monitoring strategies for prematurely born children that are appropriate to the pandemic context, ensuring a comprehensive and longitudinal care. Thus, new forms of assistance for these children become necessary, such as remote follow-up consultations in order to guarantee their right to life and health.

As a study limitation, the fact that the interviews have taken place over the phone stands out, which may have hindered the interaction between the researchers and the participants, although it may also have contributed to reduce the speech time, since in-person interviews facilitate dialog. In addition to that, the remote interview format may have weakened the apprehension of the repercussions of the pandemic on the family, since the presence of the researcher in the family environment could favor deeper understanding of the vulnerabilities of children that were born prematurely and of their families.

  • FUNDING

    Foundation for Research Support of the State of Paraíba (Fundação de Apoio à Pesquisa do Estado da Paraíba, FAPESQ) for the research project entitled “Maternal-child care given the Covid-19 pandemic: A remote care proposal”, coordinated by researcher Altamira Pereira da Silva Reichert. Process number: 40643.608.30727.15042020.

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Publication Dates

  • Publication in this collection
    01 Oct 2021
  • Date of issue
    2022

History

  • Received
    04 May 2021
  • Accepted
    21 July 2021
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