Infection prevention and control measures and recommendations for preterm infants discharged into the community: a scoping review protocol

Background: IPC recommendations aim to prevent illness and subsequent hospital re-admission. Cohesive guidance for parents of preterm infants has not been clearly established. The review objectives are to identify and map the global characteristics of infection prevention and control (IPC) measures and recommendations for parents of preterm infants discharged home to the community. Methods: The scoping review will be conducted using the JBI methodological approach for scoping reviews and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Scoping Review extension. Electronic databases will be searched and limited by publication year (1990-present day). Grey literature, reference lists and expert provided sources will be searched against pre-determined criteria. A minimum of two authors will independently screen evidence sources and chart the evidence on a pre-determined charting form. Sources including IPC measures, or recommendations for parents of preterm infants during discharge planning or in the community/home will be permitted within inclusion criteria. Limits include human studies only and evidence from 1990-present day. There are no participant or type of source exclusions. Recommendations aimed at implementation by professionals will be excluded. A descriptive summary of ndings will be presented along with diagrammatic and tabular representation. Discussion: Collated evidence will guide future targeted research which will subsequently aim to develop policy and enhance clinical approaches.

determined criteria. A minimum of two authors will independently screen evidence sources and chart the evidence on a pre-determined charting form. Sources including IPC measures, or recommendations for parents of preterm infants during discharge planning or in the community/home will be permitted within inclusion criteria. Limits include human studies only and evidence from 1990-present day. There are no participant or type of source exclusions. Recommendations aimed at implementation by professionals will be excluded. A descriptive summary of ndings will be presented along with diagrammatic and tabular representation.
Discussion: Collated evidence will guide future targeted research which will subsequently aim to develop policy and enhance clinical approaches.
Scoping Review Registration: This scoping review has been registered on the Open Science Framework (OSF) on the 4 th May 2021, registration number (pending).

Background
The World Health Organization (WHO) de nes preterm as "babies born alive before 37 weeks of pregnancy are completed". 1 The organization estimates that globally, 15 million babies are born prematurely each year and that prematurity is the leading cause of death in children <5 years (1). Literature reporting the medical, educational and behavioural consequences and complications of prematurity is vast. Pravia and Benny (2020) synthesised literature on the long-term consequences of prematurity, reporting impact on the pulmonary system (vascular and alveolar development, increased asthma risk and decreased lung function), renal system (kidney disease and interrupted nephrogenesis) cardiovascular system (cardiac and vascular insults, dysfunction, hypertension, ischemic heart disease, heart failure), central nervous system (autism, mood disorders, intellectual disability) and the endocrine system (diabetes, obesity, metabolic syndrome, osteoporosis) (2). Wide-ranging economic consequences for healthcare systems in developed countries, families and wider society must be recognised. Family consequences include caring responsibilities, cost implications of health goods/interventions, nutritional needs, domestic work and home repairs (3).
Healy et al. (2021) (4) systematically reviewed reports of quality improvement for bronchopulmonary dysplasia (BPD) and identi ed BPD (formerly Chronic Lung Disease) as the most common morbidity in premature infants. A systematic review by Chaw et al. (2019) (5) concluded that the risk of severe respiratory syncytial virus (RSV) disease is substantially higher in infants with BPD, increasing the length of hospital stay and intensive care unit stay, duration of oxygen supplementation and mechanical ventilation compared to non-BPD infants. RSV is a seasonal common respiratory virus and a leading cause of morbidity and hospitalization in the paediatric population.(6) When comparing health resource utilisation among preterm and term infants hospitalised with RSV, a systematic review by Kenmoe et al. (2020) (7) concluded that irrespective of gestation, preterm infants have poorer outcomes and greater utilisation of health resources than term infants.
A Vietnamese cohort study by Do et al. (2020) (8) found that of the 193 preterm infants studied from birth-24 months corrected age, 47% were readmitted at least once in the rst year and 22% in year two. All causes across the 2 years were due to respiratory infections (70%) followed by other infectious diseases (15%), echoing ndings of prior studies in high-income countries. Recommendations included information provision for parents regarding illnesses and preventative practices to reduce readmission rates post-discharge (8). A one-year, Austrian, observational study by Steiner, Diesner and Voitl (2019) (9) aimed to research the differences in infection number and severity between 72 preterm and 71 full-term infants. Results showed signi cantly higher infection rates and severity in the preterm infants. Ear nose and throat and respiratory infections were most frequent with predominantly gastroenteritis and respiratory infections causing hospitalization. Recommendations included post-discharge comprehensive care and parent information about increased infection risk and infection prevention measures. Measures included family member vaccination, hand hygiene and avoidance of high-risk environments (9).
The WHO de nes infection prevention and control (IPC) as a "scienti c approach and practical solution designed to prevent harm caused by infection" (10). IPC draws upon the disciplines and evidence base of infectious diseases, epidemiology and healthcare system burdens (11). Health organizations including the WHO (12,13) and European Centre for Disease Prevention and Control (14,15) have produced technical guidance, campaigns and reports to prevent and manage infections such as COVID-19. Approaches to IPC in healthcare settings include strategies such as hand hygiene, wearing personal protective equipment, social distancing, patient movement considerations (one-way systems, improved signage), isolation areas, respiratory hygiene measures, increased environmental cleaning, consideration of ventilation such as opening windows, and offering remote consultations (16). IPC public guidance has included hand hygiene education, social distancing, isolation, testing, use of face masks and restriction of movement. Less clear information has been provided to parents regarding post-discharge prevention of infection in preterm infants. Prevention of nosocomial infection in the neonatal unit has been widely studied (17)(18)(19). Despite readmission risks, less is known about parent-implemented community measures.
Bracht, Bacchini and Paes (2021) (20) surveyed 583 Canadian participants regarding parental knowledge of RSV and other respiratory infections in preterm infants, concluding that parental knowledge of prophylaxis eligibility criteria is essential. A Neonatal Network piece highlighted the need for validation of parental concern regarding RSV, pre-discharge parental education, prevention strategies listed on a prepared letter for the family and prophylaxis importance (21).Vohr et al. (2017) (22) evaluated a transition-home program in the United States of America (USA) in relation to rehospitalization rates of preterm infants and concluded that preventative strategies must include the social, environmental and medical risk factors. Austin (2007) (23) described the home-health nurse role in RSV prevention in the USA including caregiver education strategies regarding hand hygiene, visitor limitation, day-care attendance, smoking, awareness of signs and symptoms and prophylactic immunisation. Stakeholder knowledge was sought by the protocol author KC. Service users and neonatal unit staff reported vague information and recommendations given at the clinician's discretion. Neonatal unit advice varied on frequency, content and the duration of measures recommended. Despite implications for mortality, disease burden and economic impacts, recommendations are not clearly or consistently presented. This review aims to assimilate existing heterogeneous literature sources and provide clarity regarding the characteristics of recommendations.
A preliminary search of MEDLINE (EBSCO host), Prospero, the Cochrane Database of Systematic Reviews and JBI Evidence Synthesis was conducted and no current or ongoing reviews on the topic were identi ed. This provides justi cation that there is appropriate evidence and signi cance to substantiate a scoping review on this topic. The review objective is to identify and map the characteristics (form, content, context and mode of delivery) of IPC measures and recommendations for parents of preterm infants discharged home to the community. The assimilation of evidence identi ed in this scoping review will inform future research recommendations. Further research conducted from these research recommendations will aim to subsequently in uence policy and practice to mitigate the risk of infection and re-hospitalization.

Review questions
1. What IPC measures and recommendations are available for parents/caregivers of preterm infants to during discharge or on discharge home to the community? Sub Questions: i) What is the range and extent of available evidence of knowledge and provision of IPC measures and recommendations for parents/caregivers of preterm infants during discharge or on discharge home to the community to mitigate the risk and incidence of infection and readmission to hospital?
ii) What are the characteristics (form, content, context and mode of delivery) of the IPC measures and recommendations?
Eligibility criteria Participants This review will consider evidence that includes individuals who are either the provider (for example but not limited to healthcare professionals, government/third-sector organization or peers) or recipient (parent/caregiver or preterm infant) of IPC measures and recommendations for preterm infants. A preterm infant will be de ned as a baby born at < 37 weeks' gestation (1).

Concept
The core concept is parent/caregiver implemented IPC measures and recommendations and infection risk mitigation. Eligible sources must provide recommendations and or risk mitigation strategies, with the aim of prevention of community-acquired infection in the preterm child. Common IPC measures and recommendations include hand-hygiene, reduction in contact with others and environmental cleanliness.
There will be no restriction on the background of the provider or the mode or form of delivery.

Context
This review is not limited to provision of recommendations from a speci c healthcare setting or organization. The recommendations and measures to be included in this review may be recommended or provided prior to discharge of the preterm infant (for example during the discharge process, education classes or packages) or post-discharge, but with intended implementation of such recommendations to be conducted within the home or community environment by the parent/caregiver. Evidence will be excluded if it pertains to implementation of measures in a healthcare setting, by a healthcare professional, or if the implementation is not intended to be provided by the parent/caregiver of the infant. Sources are not limited by geographical location.

Types of Sources
This scoping review will have no limitation on the type of evidence source included and is inclusive of grey literature. Evidence sources may include but are not limited to primary research studies, opinion pieces, conference abstracts, pamphlets, websites, or blogs. The review will include sources of evidence from 1990-present day due to technological innovations in the eld of neonatal care.(24) Sources must be either written in the English language or have a translation available. Sources excluded by language will be recorded within the audit trail and reported to uphold transparency.

Methods/design
The proposed scoping review will be conducted in accordance with the JBI methodology for scoping reviews (25) and written using the JBI System for Uni ed Management, Assessment and Review of Information (SUMARI) (26, 27).

Search strategy
A three-step search strategy will be used, aiming to locate all eligible evidence sources.
1. An initial limited search of MEDLINE (EBSCO host) and CINAHL was undertaken to identify the breadth and availability of literature on the topic. This preliminary search strategy contained key words for population, concept and context. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the retrieved articles were used to develop a full search strategy for MEDLINE with the assistance of an academic librarian[Insert table 1: Search strategy). MeSH and key term variations were considered.
2. The search strategy, including all identi ed keywords and index terms, will be adapted for each included database and/or information source.
3. The reference list of all included sources of evidence will be screened for additional evidence sources. Searches of grey literature will be conducted via databases and repositories. When required, the authors of the papers and experts in the eld will be contacted for further information and to elicit knowledge of newly published sources. The search process will be iterative, and the search strategy may be modi ed to improve sensitivity and speci city. Any adaptations will be documented in an audit trail. Due to resource issues and translation feasibility, sources published in the English language or with an English language translation available will be included. Primary studies with an English language abstract may be included provided that appropriate information may be gathered. Studies excluded due to language will be recorded within the audit trail to uphold transparency. The review will include sources published since 1990 due to technological innovations within neonatal care (24). The search will be re-run prior to nal analysis.

Study/Source of Evidence selection
Following the search, all identi ed citations will be collated and uploaded into the EndNOTE 20 (28) citation management software by KC and duplicates removed. To mitigate the potential for disagreement, the following three-step pilot test framework will be followed: 1. 25 titles and abstracts will be selected at random.
2. All reviewers will screen the 25 titles and abstracts using the eligibility criteria and stated de nitions.
3. Formal evidence screening will commence when a minimum of 75% accuracy has been achieved (25). An additional step of piloting the charting form will take place at this point (see data extraction).
Titles and abstracts will then be screened by a minimum of two independent reviewers for assessment against the review inclusion criteria. Potentially relevant sources will be retrieved in full, and their citation details imported into the JBI System for the Uni ed Management, Assessment and Review of Information (JBI SUMARI) (JBI, Adelaide, Australia) (26, 27). The full text of selected citations will be assessed in detail against the inclusion criteria by two or more independent reviewers. If there is an unresolved disagreement following a discussion between reviewing authors, a third author will make the decision (25). Reasons for exclusion of evidence sources at full text that do not meet the inclusion criteria will be recorded and reported. Search results and the study inclusion process will be reported in full in the nal scoping review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping review (PRISMA-ScR) (29) ow diagram. The PRISMA-ScR checklist has been completed to ensure the methodological rigor of the protocol and has been submitted as a supplementary le (29).
Data Extraction Data will be extracted by a minimum of two independent reviewers using a data charting tool, with any disagreements resolved through discussion and/or an additional third reviewer. A draft charting form, adapted by the reviewers from the JBI template source of evidence details, characteristics and results extraction instrument (25) is provided [Insert table 2: Data extraction instrument]. The data extracted will include citation details, information regarding the participants, concept and context and key ndings aligned to the review questions. The form was piloted by KC during the initial search and will be piloted by all reviewers in combination with the source of evidence selection piloting process. The form may be iteratively modi ed as necessary during the data extraction process. Any revisions will be clearly documented and detailed in the scoping review. If necessary, authors of papers will be contacted to request missing or additional data, where required.

Data Analysis and Presentation
Data will be descriptively presented using a narrative summary. Frequency counts of concept characteristics will be tabulated (25). Using tabular form, assimilated categories of recommendations (for example hand hygiene, restriction of crowded locations) will be mapped against source type (for example primary study, clinical policy, third sector website) to highlight the content of recommendations. A table producing quantitative frequencies will map references against source type, categories of recommendations, delivery mode (for example pamphlet, formal education programme, website), context (for example to prevent a speci c virus during winter months) and whether parent feedback was reported.
This data may then be graphically represented. It is expected that data presentation will be re ned and expanded as the nature of the material becomes known. The evidence summary and research gaps will be presented in diagrammatic form. Competing Interests KC is a mother of a premature baby and a trustee of a neonatal charity.
Author's Contributions KC designed and produced this scoping review protocol and manuscript. DH, JR and AA contributed to the editing of this submitted manuscript. All authors read and approved the nal manuscript. TI ((recommend* or guid* or best practice or advice or protocol or policy or "follow* up" or knowledge or (identif* N3 risk) or supervis* or support* or continu* or instruct* or demonstrat* or explain* or program* or interven* or strateg* or education or (health N3 promotion) or monitor* or (care N3 plan*) or visit*)) OR AB ((recommend* or guid* or best practice or advice or protocol or policy or "follow* up" or knowledge or (identif* N3 risk) or supervis* or support* or continu* or instruct* or demonstrat* or explain* or program* or interven* or strateg* or education or (health N3 promotion) or monitor* or (care N3 plan*) or visit*)) 10,344,440 S8 (MH "Infection Control+") 65,675 S9 TI ((prevent* or reduc* or minimi* or decreas* or eliminat*) N5 (respiratory or infection or virus* or hospital* or rehospital* or admission or readmission or RSV or morbidity or mortality or risk)) OR AB ((prevent* or reduc* or minimi* or decreas* or eliminat*) N5 (respiratory or infection or virus* or hospital* or rehospital* or admission or readmission or RSV or morbidity or mortality or risk)) 623,105 S10 S8 OR S9 678,933 S11 S3 AND S6 AND S7 AND S10 1,275

Appendices
Limit 1 st January 1990 -7 th April 2021 1,241 CITATION AUTHORS Indicate all authors (last name, rst name/initial).