Thousands of elite athletes are once again participating in close-contact sport every week, and even throughout the recent “Lockdown 2.0,” and despite the ongoing covid-19 pandemic restrictions. Athletes have special concessions allowing them to contravene social distancing when considered essential for their sport to be played. The restart was facilitated by official guidance documents “Return to Domestic Competition – No Spectators” and “Behind Closed Doors”, their titles reflecting spectator bans. [1,2]

Within UK men’s and women’s senior football alone, eight international and 214 domestic teams are training and competing regularly, mixing in different locations up and down the country, and around the globe. Not to mention support staff, each match sees up to 28 players battling in close-contact sport, and teams embracing in close-celebration. [3]

Parents of babies in neonatal intensive care units (NICUs) receive no such special mitigations to enable them to be with their infants during hospitalisation. Consequently, many infants also receive their care behind closed doors, their parents shut out. Yet Bliss charity, the British Association of Perinatal Medicine (BAPM), and the Royal College of Paediatrics and Child Health (RCPCH) affirm that parents are partners in the care of their infants and not just visitors. [4,5] And all who care for babies know that optimal outcomes can only be achieved with direct parental involvement. [6] The guidance from BAPM and RCPCH specifies that parental presence should be facilitated around the clock. [4]

Despite these recommendations, visitation restrictions on NICUs persist as hospitals try to reduce footfall and maintain social distancing for the protection of all. Yet the severe restrictions have not only limited the duration of parental visits, but have prevented both parents visiting their sick and sometimes dying infants together. [7]

We recently surveyed 224 parents/guardians of babies cared for in six tertiary-level NICUs (four UK, two US). [7] Parental visiting was restricted in all units in response to the SARS-CoV-2 pandemic. Nearly two-thirds of parents perceived their NICU’s visitation policies as being too restrictive. Findings of adverse impacts on ability to visit, care for, bond with, and breastfeed their infants were as expected as they were concerning. Furthermore, the more severe the visiting restrictions, the worse the perceived impact upon parents. 

Bliss charity issued a press release recently which identified similar problems: of 242 parents surveyed 14% were unable to see their baby at all due to covid-19 restrictions and an additional 39% faced compulsory limits on visit duration. Blanket enforcement of austere hospital visiting restrictions on NICU parents was considered a major contributing issue to significant adverse impacts on their bonding, stress and mental health. [8] This survey attracted major media attention but with no discernible change in governmental policy. [9,10,11]

Why can’t the same mechanisms that enabled the restart and continuation of elite sports be applied to the UK’s 189 neonatal units? Doing so could mitigate the additional dire impact of the pandemic upon NICU parents and families. Regulations which allow athletes to tussle together in a “covid-secure” fashion, can surely be adopted and enhanced to allow both parents to be with their hospitalised neonates in an unrestricted fashion. 

Many of the specific measures that the Government introduced to allow sport to continue can be translated or adapted into practice on NICUs; indeed many similar mitigations are already in place. [1,2,12,13] A national NHS framework for COVID-secure parental visiting could be practically copied from elite sport’s guidance, but—crucially—adequate funding and political will is also essential for successful implementation of any such framework. 

More controversial measures from the guidance would likely include a ‘code of conduct’ to be signed by parents, which would mandate adherence to government advice on hygiene, mask wearing, and social distancing at all times, as well as more stringent screening measures for parents and staff—such as temperature checks on arrival and consideration of regular SARS-CoV-2 surveillance swabs.

Is it really feasible to swab NICU staff and parents regularly? Within the current football season the Premier League has completed ~1,600 tests every 5 days, and detected ~7 positive tests per round. [14] Similarly, the Women’s Super League and Championship has completed ~900 tests per week, with mean 5.3 positive results per week in the past month. [15] If the Premier League can achieve 80 tests per club every 5 days, then so could the UK’s 13 neonatal networks introduce regular testing programmes in all neonatal units. While feasible, local transmission rates will impact pre- and post-test probabilities, so regional evidence-based decisions would be needed on asymptomatic screening swabs. [16,17]

If elite sport can achieve full return to domestic and international competition—where lives are not at stake, then our goal must be full return to unrestricted parental visiting in NICUs—where matters of life and death are a daily concern.

Behind closed doors, elite sports may continue despite empty stadiums; but in the NICU precious lives and moments may pass forever without parents present. With the unique emotional, physical and psychological challenges parents face, we must remind ourselves that parents are key players, not mere spectators.

Paul Cawley, (@PaulCawleyUK) Neonatologist, London

Paul Clarke, (@drpaulclarke) Consultant Neonatologist and Honorary Professor of the University of East Anglia, Norwich

Conflict of interest: None declared

References:

1. UK Government, Department for Digital, Culture, Media & Sport. Elite sport – return to domestic competition guidance. Last accessed 05/12/2020 at: https://www.gov.uk/government/publications/coronavirus-covid-19-guidance-on-phased-return-of-sport-and-recreation/elite-sport-return-to-domestic-competition-guidance
2. Premier League. Season 2019/20 Restart Guide – Behind Closed Doors. Version 01. Last accessed 05/12/2020 at: https://resources.premierleague.com/premierleague/document/2020/06/16/aa4f9f51-f97b-4582-907b-29fabbe74f69/Premier-League-2019-20-Restart-Guide.pdf
3. Scotland National Team @ScotlandNT Oh, yes sir… #NoScotlandNoParty [Twitter]. Nov 12, 2020. Last accessed 5/11/2020 at: https://twitter.com/ScotlandNT/status/1327023447332057088?s=20
4. Royal College of Paediatrics & Child Health, & British Association of Perinatal Medicine. COVID-19: Frequently asked questions within neonatal services. November 2020. Last accessed 05/12/2020 at: https://www.rcpch.ac.uk/resources/bapm-covid-19-frequently-asked-questions-within-neonatal-services#managing-parents-and-visitors-to-the-neonatal-unit-and-or-transitional-care-unit-tcu
5. Bliss Statement: COVID-19 and parental involvement on neonatal units. Updated 6 July 2020. Last accessed 05/12/2020 at: https://s3.eu-west-2.amazonaws.com/files.bliss.org.uk/images/Bliss-Statement_Version-4.pdf?mtime=20200706153313&focal=none
6. O’Brien K, Robson K, Bracht M, et al. Effectiveness of family integrated care in neonatal intensive care units on infant and parent outcomes: a multicentre, multinational, cluster-randomised controlled trial. Lancet Child Adolesc Health 2018;2:245–54. doi:10.1016/S2352-4642(18)30039-7. Accessible at: http://www.ncbi.nlm.nih.gov/pubmed/30169298
7. Muniraman H, Ali M, Cawley P, et al. Parental perceptions of the impact of neonatal unit visitation policies during COVID-19 pandemic. BMJ Paediatrics Open. 2020;4:e000899. doi: 10.1136/bmjpo-2020-000899. Accessible at: https://bmjpaedsopen.bmj.com/content/4/1/e000899
8. Bliss. COVID-19 Press release November 2020. Obtained by personal correspondence
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12. UK Government, Department for Digital, Culture, Media & Sport. Guidance – Elite sport return to training guidance: Stage One. Last accessed 05/12/2020 at: https://www.gov.uk/government/publications/coronavirus-covid-19-guidance-on-phased-return-of-sport-and-recreation/elite-sport-return-to-training-guidance-step-one–2#guidance-for-sports-clubs-and-support-service-providers
13. UK Government, Department for Digital, Culture, Media & Sport. Guidance – Elite sport return to training guidance: Stage Two. Last accessed 05/12/2020 at: https://www.gov.uk/government/publications/coronavirus-covid-19-guidance-on-phased-return-of-sport-and-recreation/elite-sport-return-to-training-guidance-stage-two
14. Premier League. Latest statement on results of COVID-19 tests. 30/11/2020. Last accessed 05/12/2020 at: https://www.premierleague.com/news/1814863
15. The Football Association. Latest Barclays FA WSL & Women’s Championship COVID-19 Testing Results. 01/12/2020. Last accessed 05/12/2020 at: https://www.thefa.com/news/2020/jul/14/barclays-fa-womens-super-league-and-championship-covid-19-testing
16. Watson J, Whiting P, Brush J. Interpreting a covid-19 test result. BMJ 2020; 369 :m1808 Accessible at: https://www.bmj.com/content/bmj/369/bmj.m1808.full.pdf
17. Raffle A. Screening the healthy population for covid-19 is of unknown value, but is being introduced nationwide. The BMJ Opinion. 09/11/2020. Last accessed 5/12/2020 at: https://blogs.bmj.com/bmj/2020/11/09/screening-the-healthy-population-for-covid-19-is-of-unknown-value-but-is-being-introduced-nationwide/