Family Presence Policies for Pediatric Inpatient Settings During the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has impacted the United States health care system in unprecedented ways. The American Academy of Pediatrics (AAP) recognizes the importance of providing the best medical care as well as providing compassionate patient- and family- centered care for children who are in the hospital while reducing infection risk and keeping clinicians/staff safe.

Family presence policies are critical components of family-centered care for all children and are particularly important for children with special health care needs, including those with disabilities, medical complexity, and serious illness. As a component of family-centered care, family presence forms the foundation of collaboration and acknowledges that families are partners and team members in care, rather than “visitors.” Family presence policies are also important for youth and young adults with disabilities over the age of 18 who may require reasonable accommodations per the Americans with Disabilities Act. Below are a few frequently asked questions on family presence and suggestions from the AAP.

Although COVID-19 vaccination status has the potential to alter these recommendations in the future, the logistics of determining visitor COVID-19 vaccination status at this point in the pandemic is multifaceted and complex. Individual institutions may consider their own guidance based on COVID-19 vaccination status of families/caregivers.

If a family member or caregiver is asymptomatic (ie, does not have symptoms consistent with COVID-19), can they be present with pediatric patients in a hospital?

To protect the health and safety of families, patients, and health care workers, limited family presence is encouraged. The total number of individuals visiting patients throughout hospitalization should be as few as possible. To the extent feasible, asymptomatic parents or primary caregivers (e.g., legal guardians) should be encouraged to be involved in the care of their hospitalized children, although the number allowed to be present at the bedside at a given time may be limited to 1-2 at a time. Individual hospitals and institutions have likely established more specific and detailed policies.

Hospitals are encouraged to screen all families/caregivers for fever and other COVID-19 symptoms prior to visitation. Because asymptomatic individuals may also contribute to the spread of severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, all family members and caregivers who are present with pediatric patients in the hospital must wear face masks when outside the patient’s room and encouraged to wear face masks in the room. Families/caregivers should wear face masks when hospital personnel are in the patient’s room. If hospitals do not provide face masks, families/caregivers should bring their own. The CDC has developed guidance on the fit and filtration of face masks.

Special considerations may be needed for bathroom facilities used by families/caregivers when those facilities are shared with persons other than their child. Families/caregivers should not use shared spaces for eating or meeting others within the hospital personnel and should be encouraged to perform appropriate hand hygiene before and after interactions with their child.

Limitations on family presence may feel contradictory to a family-centered approach. However, these policies are imperative to protect families, children, and health care workers during the COVID-19 pandemic.

If a family member or caregiver is symptomatic for COVID-19 or has tested positive for SARS-CoV-2, can they be present with pediatric patients in a hospital?

Family members/caregivers who are symptomatic or are found to be SARS-CoV-2 positive should not be present with a pediatric patient in a hospital. An alternative caregiver who is not symptomatic or SARS-CoV2 positive should be identified whenever possible.  

We recognize that often entire family units are affected by COVID-19, resulting in an inability to find an alternative caregiver, and that in some communities, the possibility of not being able to stay with their child can prevent families from seeking care. This may be particularly true in immigrant and/or other communities with a personal or collective history of traumatic separation from family members. This may also be true for families with a personal or collective history of negative experiences within the health care system. We recommend that hospitals/institutions consider this unintended consequence on care and on health care disparities.

If an alternative caregiver is not able to be identified, hospitals/institutions should be transparent and clear that they will engage in shared decision making with families/caregivers and clinicians to discuss patient/family-centered exceptions. Culturally competent shared decision-making can be used to identify and address exceptions for extenuating circumstances if a family member is restricted because of the above issues or hospital policies. Extenuating circumstances could include, but are not limited to, end-of-life scenarios, prolonged hospitalizations, and disability, which requires family presence as part of reasonable accommodations, in accordance with the Americans with Disabilities Act.

Hospitals and other institutions are encouraged to refer to the Centers for Disease Control and Prevention for guidance on when it is safe for families/caregivers who have tested positive for COVID-19 to be around others.

If a hospitalized child is symptomatic for COVID-19 or has tested positive for SARS-CoV-2, what family presence policies should be followed?

If a child is symptomatic and/or has tested positive for SARS-CoV-2, a limit of one family member/caregiver should be preserved when possible. To minimize risk of infection, hospitals may consider some of the following strategies:

• Family members/caregivers should not leave the patient’s room while visiting (for example, to visit other areas of the hospital).
• A face mask should be worn by the family member/caregiver when in the room with the child who is hospitalized.
• Meals must be delivered directly to the patient’s room. It is recommended that hospitals develop a mechanism by which families/caregivers can have at least one meal per day delivered to their room during their stay.

What are some exceptions to limited family presence policies during the COVID-19 pandemic?

End-of-life care. End-of-life situations, as defined by a physician, may warrant a case-by-case risk analysis. Additional family members may be allowed to be present with pediatric patients. Hospitals may consider having isolated family suites for end-of-life situations.

Children, adolescents, and young adults with disabilities and/or medical complexity. Family/caregiver presence for a child, adolescent, or young adult (age 18 and older*) with disabilities or medical complexity should be assessed by individual institutions as a reasonable accommodation in alignment with the Americans with Disabilities Act and a potential exception to limited family presence policies. Hospitals are encouraged to engage in conversation and discussion with the family/caregiver or patient regarding their specific accommodation needs.

*Of note, young adults who have turned 18 and have disabilities may still need a family member/caregiver present in the hospital setting as part of reasonable accommodations (see “Resources” section for more information). In these cases, infection control procedures should be followed, and all family members/caregivers should be screened for symptoms.

How can families, caregivers, and children who are hospitalized be supported during this time?

Compassionate family- and patient-centered care should continue throughout the COVID-19 pandemic. Below are some strategies that can be utilized to promote this care in the context of limited in-person family presence policies:

• When in-person family presence is not an option, virtual presence by family members and friends for children who are in the hospital should be the standard. Families/caregivers should be informed about limited family presence policies in advance. Clinicians should partner with families/caregivers to plan for virtual presence through phone and video conferencing.
• Families/caregivers are members of the care team, and as such, communication, and familiarity with the child’s care team (even if not in-person) is critical to maintain family-centered care during this time. Clinical care teams should consider options for family/caregiver virtual participation in rounds (via video or phone conferencing). Care plans should continue to be developed in partnership with the family/caregiver, even if this planning occurs virtually.
• Psychosocial, emotional, spiritual, and developmental support are essential during this time. Child life services should be provided to assist patients and families/caregivers in coping with the stress of hospitalization. Both in-person and virtual child life interventions can support growth and development and a child’s continued need for therapeutic play, preparation, and coping strategies. These needs are experienced by children who are hospitalized for both COVID-19 and other nonrelated conditions. Other services, including palliative care, pastoral care, social work, and other mental health services, should be offered to children and families/caregivers, including those that are not able to be present in the hospital setting.
• For family members/caregivers staying with the child in the hospital, social work consults on topics such as food insecurity may also be encouraged, because some families/caregivers may not be able to bring in food from the home or have it delivered into the hospital setting.
• Consider connecting families/caregivers (especially those facing denial of family presence) to some of the following resources:
  • The child’s primary care medical home, which can assist in care coordination and referral to peer support organizations
  • Peer support organizations, such as Family Voices/Family-to-Family Health Information Centers, Parent to Parent USA, and the Courageous Parents Network
  • State Protection and Advocacy Center and/or the Arc for information on how to advocate for appropriate accommodations

Additional Information

• FAQs: Management of Infants Born to Mothers with Suspected or Confirmed COVID-19
• Breastfeeding Guidance Post Hospital Discharge for Mothers or Infants with Suspected or Confirmed SARS-Co V-2 Infection
• Centers for Medicare and Medicaid Services Guidance on Family Presence Policies for Hospitals
• COVID-19 and Patient-and Family-Centered Care FAQs (Institute for Patient- and Family-Centered Care)
• COVID Ready Communication Playbook (Vital Talk)