This survey was performed in 2017, and although the regional response rate was heterogeneous, 80% of NICUs across Italy responded. Consequently, our analysis allowed us to provide an updated picture of current DC policies and to identify urgent needs for improving DC and KMC policies across Italian NICUs.
NICU open parental access is part of the organizational and structural practices suggested by the international recommendations for health and hospital policies to improve the care of hospitalized newborn babies, thereby enabling better clinical and neuropsychological development . Over the last two decades, Italy has made significant strides towards allowing parents open access to NICUs. De Vonderweid and Leonessa  indicated from their 2001 survey that across 108 of 112 NICUs in Italy, only 29 and 24% of Italian NICUs provided open access for mothers and fathers, respectively. Similarly, in 2009, a study of eight European countries between 2004 and 2006  reported open access in only 31% of NICUs in Italy and 27% in Spain. These reported access percentages were in stark contrast to the 100% of NICUs offering open access for both parents in Sweden, Denmark, and the UK; 90% in the Netherlands and Belgium; and 72% in France. In the vast majority of the units, especially after excluding NICUs from Italy and Spain, the durations of visits were not limited, and except for some limitations during medical rounds, visits were unrestricted . Indeed, across all countries, medical rounds restricted access considerably more than other conditions. Only two countries within the European Union (EU), Spain and Italy, had time-limited open access policies for family members. Despite some improvements from 3 to 6 years prior (from 18 to 31% in Italy and from 11 to 27% in Spain), overall rates remained low .
The current survey has revealed significant progress, and the increase in persistently open units from 31 to 62% over a period of approximately 14–16 years is encouraging. Nevertheless, more work is needed to reach parity with northern European countries. In assessing whether parental access and attitudes towards parents are in accordance with a DC [15, 16] approach, our study shows that 39% of NICUs strongly limit entry times. Particularly striking is that we found that in 73% of partial-access NICUs, the average parental stay was 4 h, and further restrictions relating to shift changes, emergencies and medical rounds were reported.
Indeed, more than 64% of NICUs denied parents access to the ward during medical rounds. Another negative feature of Italian NICUs was the low percentage (45%) of units that provided access to relatives such as siblings, grandparents, uncles, and friends. We speculate that these negative aspects could be related to the fact that 70% of NICUs lacked accommodation facilities (sleeping room, family room, reading room, adjoining accommodation, dedicated kitchen). Indeed, our survey showed that a large number of NICUs do not provide a dedicated kitchen for parents or the option for a bed or accommodation near or inside the ward. Moreover, very few centres stated that they have family rooms.
The present survey showed that KMC is a well-known and widespread practice in all Italian regions; however, implementation strategies across centres were inconsistent and deviated from the WHO recommendations. The reported average time of a single KMC session and total daily KMC were 106 min and 166 min, respectively. This value falls within the minimum standard indicated by the WHO, which recommends that KMC should be performed as often as possible over 24 h, throughout the duration of the hospital stay, and at home after discharge from the hospital. Although KMC was promoted by most surveyed NICUs, restrictive policies regarding the entry of parents into the ward impede its practice. All the NICUs reported a clear (though not objectively quantifiable) relationship between access hours and the duration of KMC, where NICUs with 24-h open access allowed, on average, longer KMC sessions than NICUs with restricted access. In addition, KMC duration was further reduced in NICUs with especially restricted access times (less than 10 h per day) compared to those with access for more than 10 h per day. Limitations to KMC also reduce the opportunity for early breastfeeding [14, 17,18,19]. Our survey showed that 43% of Italian NICUs discontinue KMC early, either when the baby is transferred from the NICU to postintensive care (30%) or when the baby commences bottle feeding (13%).
Breastfeeding is usually favoured by a stable daily KMC practice [14, 19], especially for infants in intensive care. Unfortunately, the limited hours and additional restrictions for KMC across many Italian NICUs seemed to impede breastfeeding. Other factors that hindered breastfeeding in preterm infants included the lack of fresh breast milk from their mother (26%) and a lack of strategies for allowing preterm babies to breastfeed given an inability for the mother to express her breast milk at the crib side (72% of the centres) [20,21,22,23]. Mothers who can express their breast milk at the crib side can do so immediately after a KMC session, which is a natural stimulus for the oxytocin reflex [20,21,22,23]. Milk banks were present in only 45% of the units: the lack of donated human milk banks is another obstacle, as it leads to the commencement of formula milk feeding [23, 24]. Moreover, only 35% of the centres offered KMC at less than 29 weeks PMA; this figure may be due to the high percentage (26%) of vague answers, such as “when the child is stable” or similar responses. This statement does not allow the evaluation of these data with certainty; in addition, the frequent absence of shared protocols for the use of KMC and breastfeeding may ultimately limit both KMC and breastfeeding.
Strikingly, only 57% of units had written KMC protocols, with a significant gap across NICUs. This lack of written KMC protocols may indicate that staff do not perceive the presence of parents, KMC, and breastfeeding as legitimate therapeutic interventions. In contrast, evidence reported in the literature clearly stresses that empowering parents as primary caregivers, KMC, and breastfeeding are the strongest initiatives for promoting early attachment and interaction between the baby and family members [2, 6, 13,14,15,16,17,18,19,20, 24,25,26,27,28,29,30,31]. Conversely, early attachment and interaction are important early indicators for optimal child development [2, 6, 15, 17, 28, 30, 31]. Our survey outlines the need for the SIN to insist on residential courses to promote training on and the discussion, knowledge, and sharing of these concepts with NICU professionals. A survey approach, despite being difficult, complex, and time-consuming, is a vital tool for monitoring changes in DC-oriented policy throughout the country. This approach further allowed the identification of gaps and helped to uncover steps for overcoming the aforementioned restrictions. Our survey has clear limitations. Responses to a self-administered questionnaire may be subjective and reflect only the ideas of the person tasked with filling out the questionnaire and not those of the team or unit as whole. Actual inspection of the units would be ideal for checking individual unit policies and directly collecting the opinions of staff and parents. However, the actual inspection of such a large number of units throughout the country would be logistically difficult and expensive. Moreover, the subjectivity of team member responses and the lack of an accurate recording in the clinical charts of the number and length of KMC sessions are clear limitations to this study: in responses regarding KMC and breastfeeding, which are universally perceived as quality markers for the NICU, individual staff may overscore these aspects. We are planning to overcome this limitation in the next survey protocols, which will include the recording of activities with the possibility of building a “log-file” to collect measurable information, accepting the data on KMC duration only for those NICUs that perform accurate recording of the length and number of single KMC sessions.
Despite these limitations, an important strength of our survey is that the group who planned and oversaw this initiative was composed of 15 members from the DC study group board plus a number of regional contact persons who were responsible for relaying the questionnaire to individual NICUs across the 20 Italian regions. These members not only collaborated to encourage responses to the questionnaire (an 80% response rate among all Italian NICUs is a clear success) but also provided quality control given that they were familiar with individual NICUs and their specific features and protocols. Moreover, most of these experts have participated in the study since the initial discussions for the study plan and had the opportunity to see and discuss the results of the survey after the collection of the questionnaires.