Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: None
The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: None
CoSTR Citation
Dainty KN, Atkins DL, Breckwoldt J, Maconochie I, Schexnayder SM, Skrifvars MB, Tijssen J, Wyllie J, Furuta M; International Liaison Committee on Resuscitation’s (ILCOR) Pediatric, Neonatal Life Support and Education, Implementation and Teams Task Forces. Family presence during resuscitation in paediatric and neonatal cardiac arrest: A systematic review. Resuscitation. 2021 Feb 9;162:20-34. doi: 10.1016/j.resuscitation.2021.01.017. Epub ahead of print. PMID: 33577966.
Collaborators
The Pediatric Life Support Task Force of the International Liaison Committee on Resuscitation (ILCOR).
Methodological Preamble and Link to Published Systematic Review
The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review of family presence during pediatric resuscitation conducted by the Knowledge Synthesis Unit at St Michael’s Hospital, Toronto, Canada with involvement of clinical content experts {Dainty KN 2020 submitted}. Evidence for pediatric literature was sought and considered by the Pediatric and Neonatal Task Forces. These data were taken in account when formulating the treatment recommendations.
Systematic Review
Dainty KN, Atkins D, Breckwoldt J, Maconochie I, Schexnayder SM, Skrifvars MB, Tijssen J, Wyllie J, Furuta M. for the International Liaison Committee on Resuscitation’s (ILCOR) Pediatric and Neonatal Life Support Task Forces. Effect of family presence during resuscitation in pediatric cardiac arrest on patient, parent and health care provider outcomes: A systematic review {Dainty KN 2020 submitted}
PICOST
Population: In neonates requiring resuscitation in any setting
Intervention: Does family presence during resuscitation
Comparators: Compared to no family presence during resuscitation
Outcomes: Result in improved patient outcomes (short and long term), family-centered outcomes (short and long term, perception of the resuscitation), and health care provider-centered outcomes (perception of the resuscitation, psychological stress)
Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies, qualitative) are eligible for inclusion. Unpublished studies (e.g., conference abstracts, trial protocols) are excluded.
Timeframe: All years and all languages are included as long as there is an English abstract
PROSPERO Registration CRD42020140363
Data Analysis
The definition and approach to “family presence” during resuscitation was highly variable leading to great heterogeneity in the types of published studies available on this topic. The majority of the articles were observational in nature, and most collected data via surveys or using qualitative interview techniques. These articles provided low or very low-quality evidence and did not provide data which can be meta-analyzed to compare outcomes (i.e., by family presence vs. no family presence). However, the team considered that there was important knowledge to be synthesized from the research, and for this reason, a narrative review was performed.
The overall certainty of evidence was rated as very low for all outcomes. A formal assessment of risk of bias was not conducted but the studies were considered as being at high risk of bias due to selection bias. The totality of the evidence must also be considered as characterised by serious indirectness; many of the surveyed participants had not themselves participated in a resuscitation with presence of family members and in addition, healthcare providers were not necessarily analysed separately from parents or professional group. Within the studies, methods to assess risk of bias were not reported. Furthermore, the study-specific surveys were each used for one study only and were not published or validated. The total number of participants was small, and only a narrow range of socio-cultural settings was represented.
Only one study to date (July 2020) reported data on demographic patient-level resuscitation interventions and Apgar scores for family presence during neonatal resuscitation but this was demographic rather than outcome data. For family-centred outcomes (experience, perception of the resuscitation), and health care provider-centred outcomes (perception of the resuscitation, psychological stress, effect on workload) only qualitative and survey method studies (n=37) were identified, which each used a different instrument and therefore were unsuitable for a meta-analysis.
The literature on family presence during neonatal resuscitation includes eight studies, six of which were qualitative {Arnold, 2012, e002487, Harvey 2012 F439, Harvey 2013 e002547, Lindberg 2007 142, Sawyer 2015 e008495, Yoxall 2015 e008494} ,with the other two studies using survey methodology {Katheria 2018 100, Zehnder 2020 F1}.
Three of the qualitative studies focused on the experience of fathers during their baby’s resuscitation {Harvey 2012 F439, Harvey 2013 e002547, Lindberg 2007 142}, two focused on the experience of both parents {Arnold, 2012, e002487, Sawyer 2015 e008495} and one looked at provider opinion {Yoxall 2015 e008494}. One of the survey studies included both parent and provider opinions {Katheria 2018 100} and the second used the National Aeronautics and Space Administration Task Load Index (TLX) {Zehnder 2020 F1} to assess workload amongst health care providers (performance, effort, frustration, mental, physical and temporal demand). It is of note that all studies were from high resource settings and a small number of countries (UK, USA and Canada).
Consensus on Science
- For the critical outcome of improved patient outcomes (short and long term) there were no useful data to inform practice. Only one study reported Apgar scores in demographic data {Zehnder 2020 F1}.
- For the important outcome of family centered outcomes there were 7 studies reporting on 144 people, all from high resource settings. The studies included 4 surveys of parents or family members who were present during stabilization or resuscitation (Arnold 2012 e002487, Harvey 2012 F439, Lindberg 2007 142, Sawyer 2015 e008495}, 2 surveying the opinions of health care providers {Harvey 2013 e002547, Yoxall 2015 e008484} and 1 surveying both health care providers and parents {Katheria 2018 100}. Overall, the findings in these mainly qualitative studies reflected a positive experience for families who were present during the stabilization or resuscitation of their newborn babies. Qualitative themes included:
- The unique experience and perspective of fathers/partners particularly around their knowledge of what happened.
- Fathers/partners focused on their partner at the time of the resuscitation/stabilisation event.
- Parents felt that being present provided reassurance and opportunities for involvement and communication, but parents also reported some reservations about the emotional toll of witnessing a resuscitation.
- The need for staff training in support and debriefing of parents.
- Parental presence at birth was characterised by intense but polarized emotions ranging from desperation to see the baby immediately, to fear of witnessing a situation involving their baby they would rather have avoided.
- For the important outcome of health care provider outcomes, we identified 4 studies. Two of the papers surveyed opinions of health care providers who had participated in a resuscitation with family presence or delivery of the baby with all immediate care beside the mother for delayed clamping of the umbilical cord {Harvey 2013 27, Yoxall 2015 e009484}. One paper surveyed parental opinion (Sawyer 2015 e008495). One paper surveyed health care providers and found that the presence of a family member reduced perceived workload {Zehnder 2020 F1}.
Overall, health care provider participants were professionals who were used to having parents in attendance and did not report any major detrimental effects. However, some expressed concern that less experienced professionals may feel under increased pressure while being observed {Harvey 2013 27, Yoxall 2015 e008494}. This finding was not reported in the one study assessing workload {Zehnder 2020 F1}. The potential impact on staff performance was also raised as a concern by parents in one study {Sawyer 2015 e008495}.
Treatment Recommendations
We suggest it is reasonable for mothers/fathers/partners to be present during the resuscitation of neonates where circumstances, facilities and parental inclination allow. This is a weak recommendation based on very low certainty of evidence.
There is insufficient evidence to indicate an interventional effect on patient or family outcome. Being present during the resuscitation of their baby seems to be a positive experience for some parents but concerns about an adverse effect upon performance exist among both healthcare providers and family members.
Justification and Evidence to Decision Framework Highlights
In making these recommendations, the Neonatal Life Support Task Force considered the following:
- Whilst family presence during neonatal resuscitation is practiced in some settings, it has never undergone systematic review and practice varies internationally. During the COVID-19 pandemic some services have moved neonatal resuscitation sites to locations separated from parents making this question a priority for the Neonatal Life Support Task Force.
- All the included papers originate in the UK, USA or Canada.
- All the included papers related to resuscitation at birth.
- Mothers are always present at birth and it seems that most healthcare providers surveyed in included publications feel partner/support person presence should be offered but with the caveat that facilitation and support of the families requires sufficient numbers and training of personnel.
- Of note, we did not identify any eligible randomized controlled trials or large cohort studies comparing family presence to no family presence during neonatal resuscitation. We acknowledge the lack of clinical trial data for this topic in our knowledge gaps.
- It is notable that the evidence came from the opinions of only 144 parents and 350 health care providers in total, all sampled in tertiary centres in the UK, USA or Canada.
Knowledge Gaps
There were no studies identified that provided adequate comparative data to address this PICO question in the setting of a neonate receiving resuscitation at birth or within the first month of life. The majority of published work used retrospective survey or qualitative methods and included births where resuscitation was not required. There would be serious ethical constraints on performing a randomized controlled trial to address this question, among which would be the extreme difficulty of obtaining informed consent. Therefore, larger scale observational studies with appropriate quantitative and qualitative outcome and experience measures are recommended. In addition to addressing parent and health care provider-centered outcomes, studies are needed to address whether or not family presence affects the outcome of a resuscitation and whether family presence impacts decisions to continue or discontinue resuscitation.
The included studies all came from delivery rooms studied in high resource settings. Subsequent studies are needed that recruit from different socioeconomic, cultural and organizational settings.
Attachments
Evidence-to-Decision Table for Family Presence During Resuscitation
References
Arnold L. Sawyer S, Rabe H, Abbott J, Gyte G, Duley L, Ayers S, Parent’s first moments with their very preterm babies: a qualitative study. BMJ Open 2013;3: e002487
Dainty KN, Atkins D, Breckwoldt J, Maconochie I, Schexnayder SM, Skrifvars MB, Tijssen J, Wyllie J, Furuta M Effect of family presence during resuscitation in paediatric cardiac arrest on patient, parent and health care provider outcomes: A systematic review. submitted
Harvey ME, Pattison HM. Being there: a qualitative interview study with fathers present during the resuscitation of their baby at delivery. Archives of Disease in Childhood-Fetal and Neonatal Edition. 2012 Nov 1;97(6):F439-43.
Harvey ME, Pattison HM. The impact of a father's presence during newborn resuscitation: a qualitative interview study with healthcare professionals. BMJ open. 2013 Jan 1;3(3):e002547.
Katheria AC, Sorkhi SR, Hassen K, Faksh A, Ghorishi Z, Poeltler D. Acceptability of bedside resuscitation with intact umbilical cord to clinicians and patients’ families in the united states. Frontiers in pediatrics. 2018 Apr 26;6:100.
Lindberg B, Axelsson K, Ohrling K. The birth of premature infants: Experiences from the fathers’ perspective. Journal of Neonatal Nursing. 2007; 13(4):142-149
Sawyer A, Ayers S, Bertullies S, Thomas M, Weeks AD, Yoxall CW, Duley L. Providing immediate neonatal care and resuscitation at birth beside the mother: parents’ views, a qualitative study. BMJ open. 2015 Sep 1;5(9):e008495.
Yoxall CW, Ayers S, Sawyer A, Bertullies S, Thomas M, Weeks AD, Duley L. Providing immediate neonatal care and resuscitation at birth beside the mother: clinicians’ views, a qualitative study. BMJ open. 2015 Sep 1;5(9):e008494.
Zehnder E, Law BHY, Schmölzer GM. Does parental presence affect workload during neonatal resuscitation? Arch Dis Child Fetal Neonatal Ed 2020;0:F1–F3. doi:10.1136/archdischild-2020-318840