Olfactory experience mediates response to pain in preterm newborns

Co-bedding as a Comfort measure For Twins undergoing painful procedures (CComForT Trial)

Background

Co-bedding, a developmental care strategy, is the practice of caring for diaper clad twins in one incubator (versus separating and caring for each infant in separate incubators), thus creating the opportunity for skin-to-skin contact and touch between the twins. In studies of mothers and their infants, maternal skin-to-skin contact has been shown to decrease procedural pain response according to both behavioral and physiological indicators in very preterm neonates. It is uncertain if this comfort is derived solely from maternal presence or from stabilization of regulatory processes from direct skin contact. The intent of this study is to compare the comfort effect of co-bedding (between twin infants who are co-bedding and those who are not) on infant pain response and physiologic stability during a tissue breaking procedure (heelstick).

Methods/Design

Medically stable preterm twin infants admitted to the Neonatal Intensive Care Unit will be randomly assigned to a co-bedding group or a standard care group. Pain response will be measured by physiological and videotaped facial reaction using the Premature Infant Pain Profile scale (PIPP). Recovery from the tissue breaking procedure will be determined by the length of time for heart rate and oxygen saturation to return to baseline. Sixty four sets of twins (n = 128) will be recruited into the study. Analysis and inference will be based on the intention-to-treat principle.

Discussion

If twin contact while co-bedding is determined to have a comforting effect for painful procedures, then changes in current neonatal care practices to include co-bedding may be an inexpensive, non invasive method to help maintain physiologic stability and decrease the long term psychological impact of procedural pain in this high risk population. Knowledge obtained from this study will also add to existing theoretical models with respect to the exact mechanism of comfort through touch.

Trial registration

NCT00917631

Kangaroo Care modifies preterm infant heart rate variability in response to heel stick pain: pilot study

BACKGROUND

Heel stick is the most common painful procedure for preterm infants in neonatal intensive care units. Resultant pain causes adverse physiological effects in major organ systems. Kangaroo Care (KC), involving mother-infant skin-to-skin contact is a promising analgesic for infant pain; however, the effect of KC on the autonomic nervous system's response to pain is unknown.

AIM

To determine if KC results in improved balance in autonomic responses to heel stick pain than the standard method where infants remain in an incubator care (IC) for the heel stick.

STUDY DESIGN

A randomized cross-over trial.

SUBJECTS

Fourteen preterm infants, 30-32 weeks gestational age and less than 9 days postnatal age.

OUTCOME MEASURES

Infant behavioral state, heart rate, heart rate variability (HRV) indices including low frequency (LF) and high frequency (HF) power, and the LF/HF ratio measured over Baseline, Heel Warming, Heel Stick, and Recovery periods in KC and IC conditions.

RESULTS

HRV differences between KC and IC were that LF was higher in KC at Baseline (p<.01) and at Heel Stick (p<.001), and HF was higher in KC at Baseline than in the IC condition (p<.05). The LF/HF ratio had less fluctuation across the periods in KC than in IC condition and was significantly lower during Recovery in KC than in IC (p<.001).

CONCLUSIONS

Infants experienced better balance in response in KC than IC condition as shown by more autonomic stability during heel stick. KC may be helpful in mediating physiologic response to painful procedures in preterm infants.

Kangaroo Care (skin contact) reduces crying response to pain in preterm neonates: pilot results

Crying commonly occurs in response to heel stick and adversely affects the infant's physiologic stability. Minimal crying in response to pain is desired. "Kangaroo Care," skin contact between mother and infant, reduces pain and may reduce crying in response to pain. The purpose of this pilot study was to test Kangaroo Care's effect on the preterm infant's audible and inaudible crying response to heel stick. Inaudible crying has not been previously studied. A prospective randomized cross-over study with 10 preterm infants 2-9 days old (30-32 weeks' postmenstrual age) was conducted. Infants were randomly assigned to two sequences (sequence A: day 1 heel stick in Kangaroo Care [after 30 min of prone skin contact upright between maternal breasts] and day 2 heel stick in incubator [inclined, nested and prone]; or sequence B: opposite of sequence A) was conducted. Videotapes of baseline, heel warming, heel stick, and recovery phases were scored for audible and inaudible crying times. Audible and inaudible crying times for each subject in each phase were summed and analyzed by repeated-measures analysis of variance. Subject characteristics did not differ between those in the two sequences. Crying time differed between the study phases on both days (p <or= .001). When in Kangaroo Care compared with the incubator, crying time was less during the heel stick (p = .001) and recovery (p = .01) phases, regardless of sequence. Because Kangaroo Care reduced crying in response to heel stick in medically stable preterm infants, a definitive study is merited before making recommendations.

On Privileging the Role of Gaze in Infant Social Cognition

Theories of early social-cognitive development privilege infants' use of gaze as a cue to others' attention and intentions. Mutual gaze is assumed to indicate social engagement, gaze following is believed to index understanding of others' attention, and gaze alternation (between an object and a caregiver) is used to assess joint attention. This article discusses other cues (e.g., vocal and postural) on which children in other cultures and atypically developing children in Western cultures probably rely. It proposes that it is quite likely that typically developing children in Western cultures also use nongaze cues-in conjunction with gaze-in their everyday interactions with others.

The development of potentially better practices to support the neurodevelopment of infants in the NICU

OBJECTIVE

To review the existing evidence used to identify potentially better care practices that support newborn brain development.

STUDY DESIGN

Literature review.

RESULT

Sixteen potentially better practices are identified and grouped into two operational clinical bundles based upon timing for recommended implementation.

CONCLUSION

Existing evidence supports the implementation of selected care practices that potentially may support newborn brain development.

A Review of CAM for Procedural Pain in Infancy: Part II. Other Interventions

This article is the second in a two-part series reviewing the empirical evidence for complementary and alternative medicine (CAM) approaches for the management of pain related to medical procedures in infants up to 6 weeks of age. Part I of this series investigated the effects of sucrose with or without non-nutritive sucking (NNS). The present article examines other CAM interventions for procedural pain including music-based interventions, olfactory stimulation, kangaroo care and swaddling. Computerized databases were searched for relevant studies including prior reviews and primary trials. Preliminary support was revealed for the analgesic effects of the CAM modalities reviewed. However, the overall quality of the evidence for these approaches remains relatively weak. Additional well-designed trials incorporating rigorous methodology are required. Such investigations will assist in the development of evidence-based guidelines on the use of CAM interventions either alone or in concert with conventional approaches to provide safe, reliable analgesia for infant procedural pain.

Familiarity breeds content? Soothing effect of a familiar odor on full-term newborns

OBJECTIVE

This study tested the effects of familiar and unfamiliar odors during a heel stick in full-term newborns.

METHOD

Forty-four newborns were exposed to vanillin (via their mother or via their crib) or no odor prior to a heel stick. On the day of the heel stick, infants were either exposed to a familiar odor, an unfamiliar odor, or no odor before, during, and after the procedure. Crying, grimacing, and oral movements were scored.

RESULTS

Infants exposed to a familiar odor displayed little distress and more oral movements during the procedure compared to the unfamiliar group. No advantage was found when infants were exposed to an odor learned via their mother compared to when the odor was learned via the crib. Exposure to an unfamiliar odor did not lessen distress compared to exposure to no odor.

CONCLUSION

A familiar odor is effective in significantly reducing crying and grimacing during a minor painful procedure. Olfactory support is a useful intervention that may potentially help minimize deleterious effects of neonatal pain.

The effect of the odour of mother's milk on breastfeeding behaviour of premature neonates

AIM

To assess the effects of exposure to the odour of mother's milk on breastfeeding behaviour of premature neonates.

METHODS

Thirteen preterm infants born at 30-33 weeks gestational age were tested. Seven infants were randomly assigned to the milk-odour condition, 6 to the water-control condition. During week 35 post-conceptual age, each baby was exposed to the appropriate odour stimulus for 120 sec. on 5 consecutive days immediately prior to a breastfeeding attempt. The breastfeeding bout following the final odour exposure session, and a second breastfeeding session shortly before the baby left the hospital, were analysed. Babies were weighed before and after each feeding session.

RESULTS

During each breastfeeding session, babies in the milk-odour condition displayed longer sucking bouts and more bursts composed of >7 sucking movements, and also consumed more milk than the Control infants. The time spent in the hospital was significantly less for the milk-odour condition (median = 43 days vs. 55.5 days for Controls).

CONCLUSION

Brief exposure to the odour of mother's milk prior to early breastfeeding trials had a positive effect on sucking behaviour and milk ingestion of preterm babies, which in turn resulted in a shortened stay in the hospital.

La sensibilité olfactive du nouveau-né prématuré

This document reviews the main data relating to the structural and functional organisation of olfactory perception in the premature newborn. The chemoreceptive systems (main olfactory, trigeminal, vomeronasal and terminal systems) develop in different chronological orders but quite at very early stage during ontogeny. The premature newborn, despite being immature, has been shown to react to a wide variety of olfactory stimuli. Moreover, the infant seems capable of distinguishing odours of different qualities and intensities, memorising stimuli to which he is regularly exposed to, and categorising different odours based on their hedonic valence. An inventory of the olfactory stimuli to which the infant is regularly exposed to in the incubator is carried out. Several attempts to use pleasant and familiar odours to reduce stress due to separation of the infant from its mother, to promote oral feeding, to make medical procedures more acceptable, and more so, to reduce the respiratory instability of the premature infant, are described. If sustained attention is directed to the olfactory characteristics dwelling inside the incubator, the well-being, health and development of the premature newborn could be improved.

Pode a amamentação promover alívio da dor aguda em recém-nascidos?

Trata-se de um estudo de revisão cujo objetivo foi identificar a eficácia da amamentação e dos aspectos que a congregam (contato, sucção, odor e leite) como medidas não- farmacológicas no alívio da dor aguda em recém-nascidos. Os 14 artigos analisados foram obtidos pelo Medline/PubMed. Verificou-se diferenças metodológicas quanto à amostragem, procedimentos dolorosos, períodos e maneira de administrar o tratamento e variáveis mensuradas. Percebeu-se a eficácia da amamentação e dos aspectos que a congregam, no alívio da dor aguda. Percebe-se a necessidade de estudos que avaliem o seu efeito analgésico antes do procedimento doloroso, até a recuperação, tempo este, suficiente para atingir-se o efeito analgésico pós-absortivo do leite. Deve-se considerar a interação entre todos os componentes que estão contidos na amamentação.

The calming effect of a familiar odor on full-term newborns

We assessed the effectiveness of an odor (familiar or unfamiliar) in soothing healthy full-term newborns undergoing a routine heel stick. Forty-four breast-fed newborns were randomly assigned to one of four groups: Before the heel stick, Group 1 was naturally familiarized with their mother's milk odor, Group 2 was familiarized with a vanilla smell, and Groups 3 and 4 did not receive any familiarization. During and after the heel stick, Group 1 was presented with their mother's milk odor, Group 2 was presented with the familiar vanilla, Group 3 was presented with an unfamiliar odor, and Group 4 was a control group. Infants' crying, grimacing, and head movements were analyzed before, during, and after the heel stick. Results show that infants who smelled a familiar odor (their mother's milk or vanilla) cried and grimaced significantly less during the recovery phase compared with the heel stick phase. Infants who were presented with an unfamiliar odor or no odor showed no significant changes during recovery. Moreover, infants who smelled their mother's milk exhibited significantly less motor agitation during the heel stick compared with the other groups. These findings indicate that smelling a familiar odor reduces agitation during the heel stick and diminishes distress after the procedure.

Olfactory stimulation prevents apnea in premature newborns

OBJECTIVE

Methylxanthines and doxapram are currently used to treat apnea of prematurity but are not fully effective and often present undesirable side effects. The present study examines whether exposure to an odor known to modulate the infant's respiratory rate could reduce the frequency of apneic spells.

METHOD

Fourteen preterm newborns born at 24 to 28 gestational weeks presenting recurrent apnea despite caffeine and doxapram therapy were exposed to a pleasant odor diffused during 24 hours in the incubator. Efficiency of the olfactory treatment was judged by comparing frequency and severity of apneas occurring during the day of odorization with that observed the day before (baseline) and the day after (posttreatment control). Apnea was defined as any complete cessation of breathing movements for >20 seconds, or less if associated with hypoxia or bradycardia.

RESULTS

Concerning all types of apneas, a diminution of 36% was observed and seen in 12 of 14 infants. Apneas without bradycardia were reduced (44%) during the day with odorization, and this diminution affected all the infants. The frequency of apnea with moderate bradycardia (heart rate between 70 and 90 beats per minute) was maintained while the frequency of apnea associated with severe bradycardia (heart rate <70 beats per minute) decreased strongly (45%) and affected all the infants. No side effects were observed.

CONCLUSION

The introduction of a pleasant odor in the incubator is of therapeutic value in the treatment of apneas unresponsive to caffeine and doxapram.

Olfaction in the fetal and premature infant: functional status and clinical implications

This article considers olfaction as a functioning source of information for the fetus and the neonate, born on term or prematurely. It aims to present how odors are involved in the sensory continuity between the prenatal and postnatal environments and how they influence the earliest adaptive responses of newborns in the realms of self-regulation, emotional balance, feeding, and social interactions.Finally, it evaluates odors as sensory means to ameliorate the physiologic and behavioral responses of preterm infants to the adverse impacts of separation from mother, nonoral feeding, or iatrogenic distress.