‘Opportunity to bond and a sense of normality’: Parent and staff views of cuddling babies undergoing therapeutic hypothermia in neonatal intensive care: ‘CoolCuddle’

Abstract Background Currently, parents whose sick babies are undergoing three days of cooling therapy for hypoxic–ischaemic encephalopathy in neonatal intensive care units (NICUs) are not permitted to cuddle their cooled babies, due to concerns of warming the baby or dislodging breathing tubes or vascular catheters. Parents want to stay and care for their cooled babies and have reported that bonding is adversely affected when they are not permitted to hold them. Design and Participants Qualitative interviews with 21 parents of cooled babies in NICU (11 mothers and 10 fathers) and 10 neonatal staff (4 consultants and 6 nurses) explored their views and experiences of an intervention to enable parents to cuddle their cooled babies (CoolCuddle). Thematic analysis methods were used to develop the themes and compare them between parents and staff. Results Five themes were produced. Three themes were comparable between parents and staff: Closeness, a sense of normality and reassurance and support. An additional parent theme reflected their mixed feelings about initial participation as they were apprehensive, but felt that it was an amazing opportunity. Parents and staff described the closeness between parents and babies as important for bonding and breastfeeding. Fathers particularly appreciated the opportunity to hold and bond with their infants. Parents valued the reassurance and support received from staff, and the cuddles helped them feel more normal and more like a family at a very stressful time. In a final staff theme, they discussed the skills, number of staff and training needed to undertake CoolCuddle in NICU. Conclusions Parents cuddling their babies during cooling therapy enhanced parent–infant bonding and family‐centred care in NICU and was positively received. Adverse perinatal mental health, impaired mother–infant bonding and their effects on the establishment of breastfeeding may be ameliorated by introducing CoolCuddle. Patient Contribution Our parent advisors contributed to the interview topic guides and endorsed the themes from the analysis.

the psychosocial development in low-birth-weight infants. 13 Therefore, NICUs have embedded family-centred care enabling parents to have skin-skin contact or cuddling their babies, while receiving intensive care, to promote breastfeeding and bonding and enhance neurodevelopment. 14 The only published study of ten stable HIE infants treated with therapeutic hypothermia in neonatal care in the United States showed that holding was feasible, resulted in no adverse events and there was positive feedback from mothers and nurses. 15 We have developed and refined the CoolCuddle intervention that enables parents to cuddle their babies during cooling and intensive care. The CoolCuddle intervention was developed from the cuddling techniques used with parents of babies receiving intensive care and adapted for babies receiving cooling therapy, intensive care and brain monitoring. CoolCuddle was then refined with the first four families in the study by an iterative process of carefully documenting any changes made after each cuddle to produce a standard operating procedure (SOP) involving comments from nurses and parents. 16 In the CoolCuddle study with 27 cooled babies, cooling temperature, cardiorespiratory and neurophysiology were maintained within clinically acceptable limits. 17 The aim of this qualitative study was to explore and compare parent and neonatal care staff views and experiences of CoolCuddle in NICU.

| Setting
The CoolCuddle study was undertaken in two tertiary NICUs in South West England from October 2019 to December 2020. In 2020, during the COVID-19 pandemic, we were not able to deliver the CoolCuddle intervention in one NICU due to restricted access. Parent visiting was also severely restricted at this NICU, which prevented both parents from doing any cuddles. Consequently, only six cuddles were delivered in this NICU in 2020, and most of the qualitative data were collected from parents and staff at the other unit.

| The CoolCuddle intervention
Parents have their babies on a pillow on their laps, which enables them to interact with the baby and nurses to monitor the baby's wellbeing. Before being moved, the wires and tubes around the baby are gathered into two bundles and secured with Velcro at either side of the baby. The baby (with wires) is wrapped in a sheet to keep everything secure, and two (or three) nurses carefully move the baby onto the pillow on the parent's lap. Cuddles can last for up to 2 h. At the end of the cuddle, the baby is moved back to the cot and made comfortable again. 16,17

| Participants
Twenty-eight families were recruited into the CoolCuddle study, and they undertook over 70 cuddles in total with their babies within the first 4 days; one family was unable to cuddle their baby as the mother

| Analysis
Trained qualitative researchers (L. B. and J. I.), with extensive experience of evaluating health care services, conducted the thematic data analysis. Interviews were recorded, transcribed verbatim by a professional transcription service and anonymized.
Analysis of the data was an ongoing and iterative process using NVivo 11 software to organize and code the transcripts (QSR International Pty Ltd.) after each interview. Transcripts were initially coded by L. B.; parent and staff interviews were coded separately, and themes were generated. 18 Coding and candidate themes were discussed and developed with the lead qualitative researcher (J. I.) and the qualitative research group (J. I., L. B., D. O., E. C.) at regular intervals during data collection and analysis to achieve consensus. 18 Six interview transcripts were also read and coded by J. I. to compare and discuss the coding categories. Parent and staff themes were compared by charting them to highlight common overarching themes between parent and staff data. Interviews continued until data saturation was achieved, in that no new themes were arising from the data. The final themes were presented, discussed and endorsed by the study parent advisors.

| RESULTS
A total of 21 parents were interviewed from 11 families (11 babies), comprising 11 mothers and 10 fathers. Family demographics are shown in Table 1. All babies were born full-term, with birth weights similar to the average UK birth weight; all were singletons and four were first babies. Ten staff were interviewed: four neonatal consultants and six nurses (Band 5 junior nurses with several years' experience or Band 6 senior nurses); two were males and eight were females, and two were from the unit where access and cuddles were restricted.
All themes are shown in Table 2 and Figure 1. Three themes were comparable between parents and staff: closeness, reassurance and support and a sense of normality. An additional parent theme reflected their mixed feelings about initial participation and a final staff theme discusses the staff skill set, numbers of staff and training needed to undertake CoolCuddle in the NICU environment. Themes are presented with illustrative quotes: Parent quotes are identified by 'mother or father' and whether a 'first baby'; staff quotes are identified by their role.
Parents also shared some thoughts to be given to other parents who might be in a similar situation, and these are shown in Figure 2.

| Mixed feelings about CoolCuddle
Mothers and fathers described their mixed feelings about being given the chance to hold their cooled baby as overwhelming but also a fantastic opportunity, while initially being apprehensive and nervous of moving their baby from the cot and wondering whether it would be safe with all the tubes and wires connected. Parents' initial anxieties were soon dispelled while holding their baby. Fathers described how they felt this was an opportunity that they had missed out on at the birth and were very grateful to be included in their baby's care. Parents felt reassured that CoolCuddle would not have gone ahead if it was not considered medically safe.
I think it was a mixture of feelings, hard to describe. It was certainly overwhelming, and it was breath-taking in some sense, but then also heart-breaking at the same time, yeah just a mixture of those feelings, how nice it was but at the same time you're closer to reality of what's happening. So it was scary but it was really nice definitely. (#110, Father) It was fantastic because I didn't get an opportunity to hold him before he was admitted, so that was actually the first time I got to hold him, so I was almost as excited about that opportunity as I was about him being born. I was slightly wary about all the equipment… but any anxieties about that disappeared really quickly, and he actually opened his eyes and was staring at me the whole time I was cuddling him, and that was the first time he had consistently opened his eyes while he'd been in But that getting closer to what you would expect to be the normal, because I did feel that opportunity to bond had been slightly taken from me by the situation, and so by having the CoolCuddle that gave me some sort of relief that it hadn't been taken away fully. (#117, Father, 1st baby) My main question was just his safety and is it safe to pick up and how long is it safe to hold him for and will the cooling stop and just all of those medical questions, that was what I was most concerned about.
(#110, Mother) I was quite concerned with the machines, when they would be ticking and beeping, so that would be a bit of alarm every time something did go off. But then it was just a really proud feeling. (#121, Father, 1st baby) when I said is it safe and stuff, they explained why.

| Closeness
Parents felt that the cuddle gave them a chance to start to get to know their baby, which many had missed out on soon after the birth.
Fathers in particular felt that it helped them to bond with their baby and it was important for all of them, mother, father and baby, and the  Three mothers also talked about breastfeeding and how important it had been to cuddle and be close to their baby to help get breastfeeding going. Some mothers expressed their milk while sitting next to their partners who were holding the baby and others expressed milk soon after their cuddle.

| Sense of normality
Parents described having the cuddles as helping them to feel a bit more normal, to start to feel like a family and to share their baby with their wider family. They could also start to have more normal conversations with their family and friends about their baby while having a cuddle. Other studies exploring parents' perceptions of therapeutic hypothermia for HIE confirm parents' concerns about bonding following their traumatic experiences and wanting more active involvement with their infant, more information and emotional support from staff. 4,7,8,10 Delivering therapeutic hypothermia in the context of family-centred care practices in the NICU will help parents' transition to parenthood by involving them in nursing care and decisions. 19 Enabling CoolCuddle to take place during therapeutic hypothermia will help to strengthen and enable family-centred care practices for these infants in the NICU. Addressing the staffing challenges should be supported by good training (including the video and SOP) and support from existing staff with experience of CoolCuddle.

| Study strengths and limitations
The strengths of this study include conducting interviews with over half of the parents involved in CoolCuddle and gaining experiences from both mothers and fathers. This is the first study to allow fathers to hold their cooled HIE infant and to capture their views of the experience. Another strength was having parent advisors involved throughout the study to guide the interviews and discuss the findings. Limitations include the restrictions due to the COVID-19 pandemic, which precluded face-to-face interviews that might have provided more rich discussions, and the fact that fewer nurses took part in interviews than we had hoped, which limited staff views.

| CONCLUSIONS
Parents being able to cuddle their baby during cooling treatment for HIE in NICU was positively received by parents and neonatal staff as helping to facilitate parent-infant bonding and family-centred care.
Fathers particularly appreciated the opportunity to hold and bond with their baby. Adverse perinatal mental health, impaired mother-infant bonding and their effects on the establishment of breastfeeding may be ameliorated by introducing CoolCuddle, following a period of careful evaluation in more NICUs.