Skin-to-skin care for procedural pain in neonates

Parents' Perception and Use of Skin-to-Skin Care in Jeddah, Saudi Arabia: A Cross-Sectional Study

BACKGROUND

Skin-to-skin care (SSC) between newborns and their parents provides many positive outcomes for both newborns and their parents. However, there is a lack of research assessing the perception of parents, especially fathers, of SSC in Saudi Arabia.

PURPOSE

The aim of the study is to assess parents' perception of SSC in Saudi Arabia.

METHODS

This cross-sectional study used an online survey. Data were collected from a convenience sample of 140 parents of hospitalized neonates between January and June 2023. Data were collected from one private hospital (Dr. Soliman Fakeeh Hospital) and one public hospital (King Abdulla Medical Complex) in Jeddah, Saudi Arabia. The parents' perceptions of SSC were assessed using the Parents' Perceptions of SSC tool. An independent t-test was used to compare mothers and fathers in their perceptions of SSC.

RESULTS

One hundred and forty parents completed the online survey (70 females and 70 males). The majority of the parents did not use SSC with their babies (n=102, 73%), did not read or hear about the use and benefits of skin-to-skin care (n=100, 71%), and did not receive information or training on SSC from healthcare professionals (n=112, 80%). Mothers' perception of SSC was significantly higher than that of fathers (p ≤ 0.05).

CONCLUSION

Fathers' perception of SSC was lower than that of mothers. Awareness and training programs are needed to inform parents, especially fathers, regarding SSC and its benefits in Saudi Arabia.

Effects of skin-to-skin contact in supported diagonal flexion positioning on movement quality in very preterm infants at term age

BACKGROUND

Preterm birth is associated with a high risk of long-term neuromotor disabilities such as coordination of movements, deficient antigravity limb movement, less adaptive postural control strategies, head deformities… AIMS: The aim of the present study was to examine the potential positive impact of a Supported Diagonal Flexion (SDF) skin-to-skin contact (SSC) positioning on the neuromotor development and movement quality of very preterm infants at term age.

STUDY DESIGN

Monocentric prospective matched-pair case-control study.

SUBJECTS

Thirty very preterm infants and their mother were proposed either SDF SSC positioning (n = 15) or Vertical SSC positioning (n = 15).

OUTCOME MEASURES

Amiel-Tison Neurological Assessment at Term (ATNAT) and observation of the spontaneous motor activity were assessed at term corrected age.

RESULTS

Infants in the SDF group had less dolichocephaly (adj. p = .014) and arms in candlestick position (adj. p = .048). Only 3 in the SDF group against 11 in the vertical group showed nonoptimal spontaneous motor activity. Infants in the SDF group had more positive signs such as foot-to-foot contact (adj. p = .047) or arms movements toward midline (adj. p = .046 and 0.011).

CONCLUSIONS

The present study shows that nonoptimal spontaneous motor activity was increased and dolichocephaly was more common in the vertical group. Consistently with current guidelines, it is critical to consider preterm infants' postures during SSC or while in incubators or cradles.

Current Evidence for Biological Biomarkers and Mechanisms Underlying Acute to Chronic Pain Transition across the Pediatric Age Spectrum

Chronic pain is highly prevalent in the pediatric population. Many factors are involved in the transition from acute to chronic pain. Currently, there are conceptual models proposed, but they lack a mechanistically sound integrated theory considering the stages of child development. Objective biomarkers are critically needed for the diagnosis, risk stratification, and prognosis of the pathological stages of pain chronification. In this article, we summarize the current evidence on mechanisms and biomarkers of acute to chronic pain transitions in infants and children through the developmental lens. The goal is to identify gaps and outline future directions for basic and clinical research toward a developmentally informed theory of pain chronification in the pediatric population. At the outset, the importance of objective biomarkers for chronification of pain in children is outlined, followed by a summary of the current evidence on the mechanisms of acute to chronic pain transition in adults, in order to contrast with the developmental mechanisms of pain chronification in the pediatric population. Evidence is presented to show that chronic pain may have its origin from insults early in life, which prime the child for the development of chronic pain in later life. Furthermore, available genetic, epigenetic, psychophysical, electrophysiological, neuroimaging, neuroimmune, and sex mechanisms are described in infants and older children. In conclusion, future directions are discussed with a focus on research gaps, translational and clinical implications. Utilization of developmental mechanisms framework to inform clinical decision-making and strategies for prevention and management of acute to chronic pain transitions in children, is highlighted.

Effects of skin-to-skin contact on full-term infants' stress reactivity and quality of mother-infant interactions

Skin-to-skin contact (SSC) between mothers and their infants has beneficial effects in both preterm and full-term infants. Underlying mechanisms are largely unknown. This randomized controlled trial assessed whether daily SSC in full-term mother-infant dyads: (1) decreases infants' cortisol and behavioral reactivity to a mild naturalistic stressor, and (2) facilitates interaction quality between infants and mothers (i.e., improved maternal caregiving behavior and mother-infant adrenocortical synchrony). Pregnant Dutch women (N = 116) were recruited and randomly allocated to an SSC or care-as-usual condition. The SSC condition performed 1 h of SSC daily, from birth until postnatal week 5. In week 5, mothers bathed the infant (known mild stressor). Infant and maternal cortisol was sampled at baseline, 25 and 40 min after bathing, and infant and maternal behavior was rated. Results did not indicate effects of SSC on infant behavioral and cortisol reactivity to the bathing session. Similarly, no effect of SSC was found on maternal caregiving behavior and mother-infant adrenocortical synchrony. In conclusion, the findings provide no evidence that daily mother-infant SSC is associated with full-term infants' behavioral and adrenocortical stress reactivity or mother-infant interaction quality. Future studies should replicate these findings and unveil other potential mechanisms underlying beneficial effects of SSC.

Skin-to-skin SDF positioning: The key to intersubjective intimacy between mother and very preterm newborn-A pilot matched-pair case-control study

Background

Skin-to-skin contact (SSC) has been widely studied in NICU and several meta-analyses have looked at its benefits, for both the baby and the parent. However, very few studies have investigated SSC' benefits for communication, in particular in the very-preterm newborn immediately after birth.

Aims

To investigate the immediate benefits of Supported Diagonal Flexion (SDF) positioning during SSC on the quality of mother-very-preterm newborn communication and to examine the coordination of the timing of communicative behaviors, just a few days after birth.

Subjects and study design

Monocentric prospective matched-pair case-control study. Thirty-four mothers and their very preterm infants (27 to 31 + 6 weeks GA, mean age at birth: 30 weeks GA) were assigned to one of the two SSC positioning, either the Vertical Control positioning (n = 17) or the SDF Intervention positioning (n = 17). Mother and newborn were filmed during the first 5 min of their first SSC.

Outcome measures

Infants' states of consciousness according to the Assessment of Preterm Infants' Behavior scale (APIB). Onset and duration of newborns' and mothers' vocalizations and their temporal proximity within a 1-s time-window.

Results

In comparison with the Vertical group, very preterm newborns in the SDF Intervention Group spent less time in a drowsy state and more in deep sleep. At 3.5 days of life, newborns' vocal production in SSC did not differ significantly between the two groups. Mothers offered a denser vocal envelope in the SDF group than in the Vertical group and their vocalizations were on average significantly longer. Moreover, in a one-second time-frame, temporal proximity of mother-very preterm newborn behaviors was greater in the SDF Intervention Group.

Conclusion

Although conducted on a limited number of dyads, our study shows that SDF positioning fosters mother-very preterm newborn intimate encounter during the very first skin to skin contact after delivery. Our pioneer data sheds light on the way a mother and her very preterm vocally meet, and constitutes a pilot step in the exploration of innate intersubjectivity in the context of very preterm birth.

Efficacy of Skin-to-Skin Care versus Swaddling for Pain Control Associated with Vitamin K Administration in Full-Term Neonates: A Randomized Controlled Trial

OBJECTIVE

The objective of the study was to assess the efficacy of immediate skin-to-skin care (SSC) versus swaddling in pain response to intramuscular injection of vitamin K at 30 min of birth in neonates.

METHODS

Healthy full-term newborns were enrolled immediately after normal vaginal delivery and randomized in two groups, SSC and swaddling. Neonatal Infant Pain Scale (NIPS) was measured before, immediately after and at 2 min after the injection.

RESULTS

Total 100 newborns were enrolled in the study (50 in each group). The mean (SD) birth weight of newborns in the SSC and swaddling group was 2668 (256) and 2730 (348) g, respectively. NIPS was comparable between the SSC and swaddling at before [1.78 (0.58) vs. 1.96 (0.83), p = 0.21], and immediately after the injection [4.82 (0.72) vs. 5.08 (0.75), p = 0.08]. NIPS at 2 min after the injection was significantly low in the SSC group compared to the swaddling group [1.38 (0.70) vs. 2.88 (1.00), p < 0.001]. At 2 min after injection, the NIPS score was significantly lower than baseline in the SSC group (p = 0.002), while it was significantly higher in the swaddling group (p < 0.001). A significantly higher proportion of newborns had a NIPS score of more than three at 2 min after injection in the swaddling group as compared to the SSC group (22% vs. 2%, p < 0.001).

CONCLUSION

Immediate SSC was more efficacious as compared to swaddling as a pain control intervention while giving vitamin K injection.

CLINICAL TRIAL REGISTRATION

The trial is registered with the Clinical Trial Registry of India with Registration number: CTRI/2020/01/022984.

Protecting Breastfeeding during the COVID-19 Pandemic: A Scoping Review of Perinatal Care Recommendations in the Context of Maternal and Child Well-Being

The objective of this scoping review is to determine to what extent the recommendations on perinatal care protect breastfeeding during the COVID-19 pandemic. The review follows the PRISMA ScR Extension guidelines. The research was conducted in Scopus, Medline via Pubmed, and Web of Science databases from 1 March 2020 to 31 May 2021, using 392 combinations of keywords. We searched for reviews and original papers published in English providing recommendations on delivery mode, companion during labor, the possibility of skin-to-skin contact (SSC), breastfeeding, and visitors policy. After screening, 86 out of 8416 publications qualified for data extraction. The majority of them indicated that COVID-19 infection is not a sufficient reason for a cesarean section; however, on a national level, cesarean births in severely ill patients were overrepresented. A significant number of recommendations deprived mothers of the necessary support during their labor and stay in the maternity ward. A shared decision-making model was hardly visible. Only the earliest COVID-19 recommendations suspended direct breastfeeding; in later publications, decisions were related to the mother's health, but other options of natural feeding were rarely discussed.

Survey of Skin-to-Skin Contact with Obstetrics and Pediatric Nurses

Skin-to-skin, or chest-to-chest, contact (SSC) between newborns and their mothers is known as kangaroo mother care. The physiological and psychological benefits of SSC for infants and mothers are well established. The World Health Organization (WHO) recommends practicing SSC for term and preterm newborns. However, in Saudi Arabia, SSC is not practiced as widely as recommended. There is insufficient evidence of the nurses' knowledge and attitudes regarding SSC in Saudi Arabia. The aims of this study were to describe and determine relationships between knowledge, education, beliefs/attitudes, and the implementation of SSC in Jeddah, Saudi Arabia. Thank You for Your Time and Kind Suggestion Methods: Cross-sectional descriptive data were collected from 40 nurses using an English-language version of a knowledge, beliefs/attitudes, education, and implementation questionnaire used by others. Results: The mean age of the nurses was 42.4 years (SD = 3.2), with a mean experience of 12 years (SD = 2.1). The mean total score of SSC knowledge was 13.6 (SD = 2.3), the mean of total score of attitudes/beliefs was 12.3 (SD = 3.1), the SSC education mean score was 17.1 (SD = 3.4), and the SSC implementation mean score was 17.0 (SD = 4.1). In total, 55% of the nurses were not sure of the impact of SSC on brain development in neonates, 45% could not interpret infants' responses during SSC; 67% disagreed that it was the nurses' responsibility to facilitate SSC, 37.5% were not aware of SSC guidelines, and 47% of the nurses had not received any continuing education on SSC in their units. Pearson correlations revealed a significant association between SSC implementation and nurses' knowledge level (r = 0.297, p = 0.031), education (r = 0.85, p = 0.015), and beliefs (r = 0.31, p = 0.024). Conclusions: Once nurses have improved their knowledge, education, and beliefs/attitudes, SSC implementation may concomitantly increase. A continuing education program and clear guidelines are needed to promote SSC adoption in practice.

Perception of Stress and Styles of Coping with It in Parents Giving Kangaroo Mother Care to Their Children during Hospitalization in NICU

The experience of hospitalization of a newborn in the Neonatal Intensive Care Unit (NICU) may become distressing both for the baby and parent. The study aimed to assess the degree of parental stress and coping strategies in parents giving KMC to their babies hospitalized in NICU compared to the control group parents not giving KMC. The prospective observational study enrolled a cohort of 337 parents of premature babies hospitalized in NICU in 2016 in Eastern Poland. The Parental Stressor Scale: Neonatal Intensive Care Unit, Coping Inventory for Stressful Situations were used. The level of stress in parents giving KMC was defined as low or moderate. Analysis confirmed its greater presence in the group of parents initiating KMC late (2–3 weeks) compared to those starting this initiative in week 1 of a child’s life. An additional predictor of a higher level of stress in parents initiating KMC “late” was the hospital environment of a premature baby. Task oriented coping was the most common coping strategy in the study group. KMC and direct skin-to-skin contact of the parent with the baby was associated with a higher level of parental stress only initially and decreased with time and KMC frequency.

Belgian Consensus Recommendations to Prevent Vitamin K Deficiency Bleeding in the Term and Preterm Infant

Neonatal vitamin K prophylaxis is essential to prevent vitamin K deficiency bleeding (VKDB) with a clear benefit compared to placebo. Various routes (intramuscular (IM), oral, intravenous (IV)) and dosing regimens were explored. A literature review was conducted to compare vitamin K regimens on VKDB incidence. Simultaneously, information on practices was collected from Belgian pediatric and neonatal departments. Based on the review and these practices, a consensus was developed and voted on by all co-authors and heads of pediatric departments. Today, practices vary. In line with literature, the advised prophylactic regimen is 1 or 2 mg IM vitamin K once at birth. In the case of parental refusal, healthcare providers should inform parents of the slightly inferior alternative (2 mg oral vitamin K at birth, followed by 1 or 2 mg oral weekly for 3 months when breastfed). We recommend 1 mg IM in preterm <32 weeks, and the same alternative in the case of parental refusal. When IM is perceived impossible in preterm <32 weeks, 0.5 mg IV once is recommended, with a single additional IM 1 mg dose when IV lipids are discontinued. This recommendation is a step towards harmonizing vitamin K prophylaxis in all newborns.

The Effect of Breastfeeding, Kangaroo Care, and Facilitated Tucking Positioning in Reducing the Pain During Heel Stick in Neonates

PURPOSE

Invasive intervention can negatively affect prognosis, behavior, environmental adaptation in neonates. Some nonpharmacological pain management methods are used for effective pain treatment. This study investigated the effect of breastfeeding, kangaroo care, and facilitated tucking positioning on heel-stick pain in neonates.

DESIGN

A quasi-experimental design was employed. The study was conducted in three family health centers in Kütahya/Turkey. The sample consisted of 140 healthy neonates with the gestational age of 37 weeks or more, birth weight greater than 2500 g, and no sucking problems. The sample was divided into four groups (breastfeeding, kangaroo care, facilitated tucking position, and control). Data were collected using a Baby-Mother Characteristics Questionnaire, a Physiological Parameter Follow-up Form, and the Neonatal Infant Pain Scale. Data were analyzed using chi-square, the one-way analysis of variance (ANOVA), Kruskal-Wallis, Student t-test, and Mann-Whitney U tests. The research adhered to ethical principles.

RESULTS

The facilitated tucking position group cried less and experienced less pain during heel stick than the other groups (p < 0.05). Breastfeeding, kangaroo care, and facilitating tucking help reduce heel-stick pain but facilitating tucking causes less crying and imposes less pain on neonates than the other methods.

CONCLUSION

Facilitated tucking position may be preferred to reduce pain during heel stick.

PRACTICE IMPLICATIONS

Using facilitated tucking positions and breastfeeding methods can assist healthcare professionals as supportive methods in pain management.

Comparison of peribulbar block and subtenon infiltration in pediatric enucleation for retinoblastoma

Purpose:

Enucleation performed in children with retinoblastoma is associated with severe postoperative pain. The use of opioids for the pain is associated with numerous complications which demand careful monitoring. Subtenon infiltration and peribulbar block are useful in ameliorating pain perioperatively following various ophthalmic surgeries which are yet to be evaluated in enucleation. Therefore, we designed this study to compare the effects of peribulbar block and subtenon infiltration on postoperative pain with opioids in pediatric enucleation surgeries.

Methods:

60 children of American Society of Anesthesiologists grade I and II, age ranging from 6 months to 6 years with retinoblastoma undergoing enucleation surgery were included in the study. Group A (n = 20): received peribulbar block (peribulbar group); Group B (n = 20): received subtenon local infiltration (subtenon group); and Group C (n = 20): no block was given.

Results:

The postoperative fentanyl consumption was lowest with Group B compared to Group A and Group C (P value 0.001). However, the total fentanyl consumption was comparable between groups A and B, while it was significantly higher in the control group. The mean pain score face, legs, activity, cry, consolability (FLACC) scale and mean time to discharge from post anesthesia care unit were lowest in Group B followed by Group A, while Group C had the highest. There was no statistically significant difference among the 3 groups with regards to side effects.

Conclusion:

Subtenon infiltration showed significantly better outcomes when compared to peribulbar block and intravenous opioids alone without any untoward adverse effects.

Women's experiences of skin-to-skin cesarean birth compared to standard cesarean birth: a qualitative study

BACKGROUND

Skin-to-skin contact between mother and infant immediately after birth is recommended regardless of delivery method; however, it is less common after cesarean delivery. We aimed to describe and compare women's experiences of cesarean birth with and without skin-to-skin contact at an urban tertiary care hospital.

METHODS

In this hermeneutic phenomenologic study, we used semistructured telephone interviews from 2015 to 2018 to interview a convenience sample of women who delivered at term by scheduled skin-to-skin cesarean birth at an urban tertiary care hospital in Toronto, Ontario. Women were invited to participate if they had had a previous planned or unplanned cesarean birth and a scheduled skin-to-skin cesarean birth between 2013 and 2017. Participants were excluded if they had antenatally diagnosed conditions, they delivered before 37 weeks, they had general anesthesia, their condition was unstable at the time of surgery, a skin-to-skin cesarean birth was not possible or they declined skin-to-skin cesarean birth. Interviews were recorded, transcribed and analyzed by means of thematic analysis.

RESULTS

Ten women were interviewed 1-19 months postpartum. Four central themes emerged: support for skin-to-skin cesarean birth (women feeling supported by their families and health care providers); control (participants experiencing greater control during their skin-to-skin cesarean birth); connection with the infant, which enabled women to be active participants in their delivery, enhanced bonding and intimacy, facilitated breastfeeding and bolstered confidence during early parenthood; and logistic considerations, with participants recognizing that skin-to-skin cesarean birth required additional resources.

INTERPRETATION

These findings refine what is known about skin-to-skin cesarean birth and provide a critical perspective, that of mothers. They support the transformation of traditional operating room dynamics to a more patient-centred environment.

Procedural Pain in Hospitalized Neonates in Kenya

PURPOSE

The study was conducted to understand the nature and frequency of painful procedures and use of analgesia in neonatal units in Kenya.

DESIGN AND METHODS

Descriptive prospective study was conducted in a regional Level I and a university-affiliated Level II neonatal unit in Western Kenya. Two hundred term and preterm neonates who were hospitalized during the first day of life were recruited. A validated checklist was used to audit medical charts of hospitalized neonates. Painful procedures and pain treatment interventions accompanying all procedures performed during the first seven days of hospitalization were documented. Descriptive statistics, t-tests and χ² were usedto determine frequency and factors influencing the frequency of procedures.

RESULTS

A total of 1693 painful procedures (mean = 1.6 ± 1.1) were performed with most of them being tissue-damaging (n = 1291) including intravenous cannulation and intramuscular injection. Neonates were less likely to undergo procedures if there were born at term (RR 0.85; 95% CI, 0.76-0.95, p = .003) but more likely to experience procedures if admitted in a higher level of care (RR 1.57, 95% CI, 1.43-1.74, p < .001). Only one procedure was accompanied by analgesia.

CONCLUSIONS

Neonates underwent few but highly invasive procedures without analgesia. Prematurity and a high level of care predisposed neonates to a higher burden of pain.

IMPLICATIONS

Our findings underscore the urgent need for development of context-specific clinical practice guidelines on procedural pain treatment in sub-Saharan Africa.

State of the Art in Parent-Delivered Pain-Relieving Interventions in Neonatal Care: A Scoping Review

Introduction: Parents' active involvement during painful procedures is considered a critical first step in improving neonatal pain practices. Of the non-pharmacological approaches in use, the biopsychosocial perspective supports parent-delivered interventions, in which parents themselves mediate pain relief, consistent with modern family-integrated care. This scoping review synthesizes the available research to provide an overview of the state of the art in parent-delivered pain-relieving interventions. Methods: A scoping review was performed to achieve a broad understanding of the current level of evidence and uptake of parent-driven pain- and stress-relieving interventions in neonatal care. Results: There is a strong evidence for the efficacy of skin-to-skin contact and breastfeeding, preferably in combination. These parent-delivered interventions are safe, valid, and ready for prompt introduction in infants' pain care globally. Research into parents' motivations for, and experiences of, alleviating infant pain is scarce. More research on combined parent-delivered pain alleviation, including relationship-based interventions such as the parent's musical presence, is needed to advance infant pain care. Guidelines need to be updated to include infant pain management, parent-delivered interventions, and the synergistic effects of combining these interventions and to address parent involvement in low-income and low-tech settings. Conclusions: A knowledge-to-practice gap currently remains in parent-delivered pain management for infants' procedure-related pain. This scoping review highlights the many advantages of involving parents in pain management for the benefit not only of the infant and parent but also of health care.

Kangaroo mother care practice, knowledge, and perception among NICU nurses in Riyadh, Saudi Arabia

Background

The imapct of Kangaroo Mother Care (KMC) in neonates is positively reported in the literature. However,several challenges hindered the wide-scale application of this practice.

Objectives

To assess the levels of knowledge and competency of kangaroo mother care (KMC) among nurses and to identify the potential barriers to practice.

Methodology

Structured web-based questionnaires were submitted to nurses working at neonatal intensive care units (NICUs) located in Riyadh, Saudi Arabia. The participants were asked to answer 23 questions distributed in four main domains, namely, demographic data, knowledge about KMC, practice levels, and barriers to KMC practice. For answers to the knowledge and barriers to practice domains, the mean scores (standard deviations) were calculated to present participants’ perceptions and beliefs from 1 (strongly disagree) to 5 (strongly agree).

Results

Two hundred nine NICU nurses responded (95.2% females, 89.5% working in a government hospital, 69.9% obtained a Bachelor’s degree). The majority of respondents perceived KMC as promoting maternal-infant bonding (4.47 ± 1.3) and enhancing successful breastfeeding (4.44 ± 0.9), while there were considerable uncertainties about KMC application in infants weighing < 1000 g (2.21 ± 1.2). Most of the nurses encouraged parents to perform KMC (92.8%) and provided sufficient information to optimize practice (90%). However, several barriers were apparent, including fear of accidental extubation, lack of time due to workload, familial reluctance to initiate KMC, and lack of privacy during KMC practice.

Conclusion

There is reasonable knowledge among NICU nurses, and most of them are actively engaged in practice. There is an urgent need to address the reported barriers through the implementation of clear practice guidelines, provision of suitable educational programs, optimization of staff numbers, and financial support for the development of areas conducive to KMC.

Skin-to-Skin Care by Mother vs. Father for Preterm Neonatal Pain: A Randomized Control Trial (ENVIRON Trial)

Objective

To compare skin-to-skin care (SSC) given by mother and father for preterm neonatal pain control by premature infant pain profile (PIPP) score.

Methods

64 stable preterm (28-36 weeks gestational age) neonates born at a level-3 neonatal intensive care unit were included in the trial. Random allocation with the help of a computer-generated sequence was done. In group A, SSC was given by the mother 15 minutes before the first heel-stick, and subsequently, SSC was given by the father before the second heel-stick. In group B, the sequence of SSC provider was reversed. Blinded PIPP score assessment at 0, 1, and 5 minutes of heel-stick were done by two independent assessors using video recording.

Results

The mean (SD) birth weight was 1665.18 (339.35) grams, and mean (SD) gestational age was 34.28 (2.24) weeks. The PIPP score at 0, 1, and 5 minutes had no statistical or clinically significant differences between both groups (PIPP score mean (SD) at 0 minute = 3.20 (1.11) vs. 3.01 (1.29), p value = 0.38; 1 minute = 8.59 (4.27) vs. 8.26 (4.08), p value = 0.66; 5 minutes = 3.79 (1.40) vs. 3.93 (1.99), p value = 0.65 in SSC by mother and father group, respectively). Furthermore, there was no statistical difference between the groups for any components of the PIPP score (all p values > 0.05). The PIPP score at 5 minutes almost attained the 0-minute level in both the groups.

Conclusion

Father is as effective as the mother for providing skin-to-skin care for preterm neonatal pain control. This trial is registered with CTRI/2018/01/016783.

[Pediatric pain treatment and prevention for hospitalized children]

INTRODUCTION

Prevention and treatment of pain in pediatric patients compared with adults is often not only inadequate but also less often implemented the younger the children are. Children 0 to 17 years are a vulnerable population.

OBJECTIVES

To address the prevention and treatment of acute and chronic pain in children, including pain caused by needles, with recommended analgesic starting doses.

METHODS

This Clinical Update elaborates on the 2019 IASP Global Year Against Pain in the Vulnerable "Factsheet Pain in Children: Management" and reviews best evidence and practice.

RESULTS

Multimodal analgesia may include pharmacology (eg, basic analgesics, opioids, and adjuvant analgesia), regional anesthesia, rehabilitation, psychological approaches, spirituality, and integrative modalities, which act synergistically for more effective acute pediatric pain control with fewer side effects than any single analgesic or modality. For chronic pain, an interdisciplinary rehabilitative approach, including physical therapy, psychological treatment, integrative mind-body techniques, and normalizing life, has been shown most effective. For elective needle procedures, such as blood draws, intravenous access, injections, or vaccination, overwhelming evidence now mandates that a bundle of 4 modalities to eliminate or decrease pain should be offered to every child every time: (1) topical anesthesia, eg, lidocaine 4% cream, (2) comfort positioning, eg, skin-to-skin contact for infants, not restraining children, (3) sucrose or breastfeeding for infants, and (4) age-appropriate distraction. A deferral process (Plan B) may include nitrous gas analgesia and sedation.

CONCLUSION

Failure to implement evidence-based pain prevention and treatment for children in medical facilities is now considered inadmissible and poor standard of care.

It's not age that prevents sexual activity later in life

OBJECTIVE

To describe key factors that facilitate sexual behaviour in later life.

METHODS

Re-analysis of data from a study of 2,374 Dutch older adults.

RESULTS

Partner availability, gender and health are likely to be more important factors influencing sexual behaviour engagement than the factor of age in later life. Lack of partner availability, traditional gender roles and poor health are associated with older age. However, current generations of older adults will be more capable, less ashamed of their sexual desires and engage in more sexual behaviour than prior generations.

CONCLUSION

This analysis observed that sexual activity is associated with partner availability and better health, rather than age, countering stereotypes of decline in sexual behaviour and normalising sexual activity and desire in later life.

The effect of facilitated tucking position during painful procedure in pain management of preterm infants in neonatal intensive care unit: a systematic review and meta-analysis

We performed a systematic review and meta-analysis to investigate the effects of facilitated tucking position during painful procedure in pain management of preterm infants. We searched MEDLINE, PEDro, SciELO and the Cochrane Library (until June 2019) for randomized controlled trials. An α value ≤ 0.05 was considered significant. Heterogeneity among studies was examined with Cochran's Q and I² statistic, in which values greater than 40% were considered indicative of high heterogeneity and random-effects model was chosen. Analyses were performed with Review Manager 5.3. Fifteen studies met the eligibility criteria, including 664 preterm infants. The meta-analyses showed a significant reduction in pain of - 1.02 (95% CI - 1.7 to - 0.4, N = 216) during endotraqueal suctioning for participants in the facilitated tucking position group (FTPG) compared with routine care group. The meta-analyses showed a non-significant difference in pain - 0.3 (95% CI - 2.05 to - 1.4, N = 88) during heel stick for participants in the FTPG compared with oral glucose group. The meta-analyses showed a non-significant difference in pain for participants in the FTPG compared with oral opioid group 0.2 (95% CI - 1.4 to 1.8, N = 140).Conclusion: Facilitated tucking position may improve the pain during painful procedures.What is Known:• Exposure of premature babies to painful procedures is associated with changes in brain development, regardless of other factors.• Facilitated tucking reduces the expression of pain in premature infants.What is New:• Facilitated tucking position was efficient in pain management of preterm infants when compared to routine care.• Facilitated tucking compared to opioid or oral glucose did not achieve a significant reduction in pain intensity.

Fostering mother-very preterm infant communication during skin-to-skin contact through a modified positioning

BACKGROUND

Skin-to-skin contact (SSC) has been widely studied in NICU and several meta-analyses have looked at its benefits both for the baby and the parent. Very few studies however have investigated benefit for communication.

AIMS

Investigate the immediate benefits of Supported Diagonal Flexion (SDF) positioning during SSC on the quality of mother - very-preterm infant communication and to gain insight into how mothers' and very-preterm infants' communicative behaviours are coordinated in time just a few days after birth.

SUBJECTS AND STUDY DESIGN

Monocentric prospective matched-pair case-control study. Thirty-four mothers and their very preterm infants (27 to 31 + 6 weeks GA; mean age at birth 30: weeks GA) were assigned to one of the two SSC positioning, either the Vertical Control (n = 17) or the SDF Intervention positioning (n = 17). Mother and infant were filmed during the first 5 min of SSC, 15 days after the very first SSC (i.e. 18 days after very premature birth, i.e. on average 32.4 weeks GA).

OUTCOME MEASURES

Infants' state of consciousness according to the Assessment of Preterm Infants' Behavior scale. Onset and duration of infants' and mothers' smiles, gazes and vocalizations, and their temporal proximity inside a 1-sec time-window.

RESULTS

In the SDF Intervention Group, very preterm infants vocalized three times more and mothers vocalized, gazed at their baby's face, and smiled more than in the Vertical Control Group. Moreover, in a one-second time-frame, temporal proximity of mother-infant behaviours was greater in the SDF Intervention Group.

CONCLUSIONS

Our study shows that SDF positioning creates more opportunities for mother-infant communication during SSC. SDF positioning fosters a greater multimodal temporal proximity thus supporting a more qualitative mother-infant communication.

Efficacy of Sucrose in Reducing Pain during Immunization among 10- to 18-Month-Old Infants and Young Children: A Randomized Controlled Trial

PURPOSE

Sucrose is recommended to reduce pain associated with vaccination in neonates. However, research results concerning its effectiveness in infants and young children are inconclusive. This study aims to determine the efficacy of sucrose administration in reducing pain during immunization in 10- to 18-month-old infants and young children as assessed by behavioral pain parameters, crying time, and saliva substance (P) concentration.

DESIGN AND METHODS

This was a double-blind, randomized controlled trial and included healthy infants and young children undergoing their 10- to 18-month immunization. Behavioral pain outcome was measured during, and shortly after the last injection. The infant's pain was also measured by a salivary test using substance (P), and videotaping of crying time.

RESULTS

The study results indicate that, compared with a placebo group, the sucrose group had significantly less pain post-immunization (F (1,129) = 1.72, p = 0.001). Moreover, substance (P) was lower in the intervention group post-immunization, and it could be considered a good predictor of pain reduction associated with immunization.

CONCLUSIONS

Sucrose administration during immunization injection helps in reducing pain, which is one of the most critical factors affecting compliance with the immunization schedule. Substance (P) measurement can be used as a predictor of immunization pain level in 10- to 18-month-old infants and young children.

PRACTICE IMPLICATIONS

Sucrose is an effective method to reduce needle pain during immunization; therefore, healthcare providers should administer sucrose as a pain relief intervention in the immunization clinical setting.

Pediatric pain treatment and prevention for hospitalized children

Introduction:

Prevention and treatment of pain in pediatric patients compared with adults is often not only inadequate but also less often implemented the younger the children are. Children 0 to 17 years are a vulnerable population.

Objectives:

To address the prevention and treatment of acute and chronic pain in children, including pain caused by needles, with recommended analgesic starting doses.

Methods:

This Clinical Update elaborates on the 2019 IASP Global Year Against Pain in the Vulnerable “Factsheet Pain in Children: Management” and reviews best evidence and practice.

Results:

Multimodal analgesia may include pharmacology (eg, basic analgesics, opioids, and adjuvant analgesia), regional anesthesia, rehabilitation, psychological approaches, spirituality, and integrative modalities, which act synergistically for more effective acute pediatric pain control with fewer side effects than any single analgesic or modality. For chronic pain, an interdisciplinary rehabilitative approach, including physical therapy, psychological treatment, integrative mind–body techniques, and normalizing life, has been shown most effective. For elective needle procedures, such as blood draws, intravenous access, injections, or vaccination, overwhelming evidence now mandates that a bundle of 4 modalities to eliminate or decrease pain should be offered to every child every time: (1) topical anesthesia, eg, lidocaine 4% cream, (2) comfort positioning, eg, skin-to-skin contact for infants, not restraining children, (3) sucrose or breastfeeding for infants, and (4) age-appropriate distraction. A deferral process (Plan B) may include nitrous gas analgesia and sedation.

Conclusion:

Failure to implement evidence-based pain prevention and treatment for children in medical facilities is now considered inadmissible and poor standard of care.

Mothers' Perceptions about Pain in Hospitalized Newborn Infants in Kenya

PURPOSE

Explore views of mothers about pain and pain treatment practices in hospitalized newborn infants.

DESIGN AND METHODS

A Qualitative descriptive study using photo-elicitation technique was conducted in a level I and a level II neonatal units in Kenya. Fifteen semi-structured interviews were conducted with mothers of hospitalized infants. The interviews were audio-recorded, transcribed verbatim and analysed using inductive content analysis approach.

RESULTS

Mothers described the experience of witnessing their infants undergo painful procedures as emotionally and psychologically traumatic. Participants felt helpless for not being able to protect their infants from pain a situation which was made worse by health care providers who appeared less concerned about pain relief during procedures. Mothers' views demonstrated a good understanding of pain-relief strategies; they identified strategies that health care providers should routinely use to relief pain in hospitalized infants. Furthermore, participants desired to be involved in comforting their infants during clinical procedures.

CONCLUSION

Repeated and untreated painful procedures continue to define the hospitalisation experience of newborn infants despite the presence of mothers who desire to be involved in comforting their infants during procedures.

PRACTICE IMPLICATION

Minimizing the burden of pain and using pain-relieving interventions could reduce parental stress and optimize parental role attainment following hospitalisation.

Mitigating Infant Medical Trauma in the NICU: Skin-to-Skin Contact as a Trauma-Informed, Age-Appropriate Best Practice

Infant medical trauma in the NICU is associated with serious and lasting consequences. Skin-to-skin contact (SSC) of infants with their parents is a nursing intervention that provides significant benefits and can mitigate the negative consequences of the infant's traumatic experiences in the NICU. The purpose of this article is to explain how SSC aligns with the concept of trauma-informed age-appropriate care (TIAAC) in the NICU. The evidence supporting SSC will be reviewed and discussed using TIAAC as a framework. SSC is an effective and evidence-based care strategy that reduces the infant's traumatic NICU experiences by improving parental proximity, attachment, and lactation; decreasing stress and pain; improving physiologic stability; supporting sleep; and enhancing neurologic outcomes.

Reducing toxic stress in the neonatal intensive care unit to improve infant outcomes

In 2011, the American Academy of Pediatrics (AAP) published a technical report on the lifelong effects of early toxic stress on human development, and included a new framework for promoting pediatric health: the Ecobiodevelopmental Framework for Early Childhood Policies and Programs. We believe that hospitalization is a specific form of toxic stress for the neonatal patient, and that toxic stress must be addressed by the nursing profession in order to substantially improve outcomes for the critically ill neonate. Approximately 4% of normal birthweight newborns and 85% of low birthweight newborns are hospitalized each year in the highly technological neonatal intensive care unit (NICU). Neonates are exposed to roughly 70 stressful procedures a day during hospitalization, which can permanently and negatively alter the infant's developing brain. Neurologic deficits can be partly attributed to the frequent, toxic, and cumulative exposure to stressors during NICU hospitalization. However, the AAP report does not provide specific action steps necessary to address toxic stress in the NICU and realize the new vision for pediatric health care outlined therein. Therefore, this paper applies the concepts and vision laid out in the AAP report to the care of the hospitalized neonate and provides action steps for true transformative change in neonatal intensive care. We review how the environment of the NICU is a significant source of toxic stress for hospitalized infants. We provide recommendations for caregiving practices that could significantly buffer the toxic stress experienced by hospitalized infants. We also identify areas of research inquiry that are needed to address gaps in nursing knowledge and to propel nursing science forward. Finally, we advocate for several public policies that are not fully addressed in the AAP technical report, but are vital to the health and development of all newborns.

Pilot Testing a Robot for Reducing Pain in Hospitalized Preterm Infants

Optimizing neurodevelopment is a key goal of neonatal occupational therapy. In preterm infants, repeated procedural pain is associated with adverse effects on neurodevelopment long term. Calmer is a robot designed to reduce infant pain. The objective of this study was to examine the effects of Calmer on heart rate variability (HRV) during routine blood collection in preterm infants. In a randomized controlled pilot trial, 10 infants were assigned to either standard care ( n = 5, facilitated tucking [FT]) or Calmer treatment ( n = 5). HRV was recorded continuously and quantified using the area (power) of the spectrum in high and low frequency (HF: 0.15-0.40Hz/ms2; LF: 0.04-0.15 Hz/ms2) regions. Changes in HRV during three, 2-min phases (Baseline, Heel Poke, and Recovery) were compared between groups. Calmer infants had 90% greater parasympathetic activation ([PS] reduced stress) during Baseline, 82% greater PS activation during Poke, and 24% greater PS activation during Recovery than FT infants. Calmer reduced physiological preterm infant pain reactivity during blood collection.

Expanding Regulation Theory With Oxytocin: A Psychoneurobiological Model for Infant Development

BACKGROUND

Oxytocin (OT), an affiliation hormone released during supportive social interactions, provides an exemplar of how social environments are reflected in our neurobiology from the beginning of life. A growing body of OT research has uncovered previously unknown functions of OT, including modulation of parenting behaviors, neuroprotection, affiliation, and bonding. Regulation theory provides a strong framework for describing how the maternal care environment affects infant neurodevelopment through a symphony of molecules that form the neurobiological milieu of the developing infant brain.

OBJECTIVES

The purpose of this article was to expand on regulation theory by discussing how OT-based processes contribute to infant neurobiology and by proposing a new model for maternal-infant nursing practice and research.

APPROACH

We structure our discussion of the socially based, neurobiological processes of OT through its effects in the nested hierarchies of genetic, epigenetic, molecular, cellular, neural circuit, multiorgan, and behavioral levels. Our discussion is also presented chronologically, as OT works through a positive feedback loop during infant neurodevelopment, beginning prenatally and continuing after birth.

IMPLICATIONS

Nurses are in a unique position to use innovative discoveries made by the biologic sciences to generate new nursing theories that inform clinical practice and inspire the development of innovative interventions that maximize the infant's exposure to supportive maternal care.

Sucrose vs. skin to skin care for preterm neonatal pain control-a randomized control trial

OBJECTIVE

To compare the efficacy of SSC with oral Sucrose for pain management in preterm neonates.

METHODOLOGY

Parallel-group, assessor-blinded randomized control trial conducted from February-June 2017 at a level 3B-NICU. Hundred preterm neonates (29-0/7 to 36-6/7 weeks gestational age) requiring heel-stick were randomly assigned (1:1), to SSC (50, Group-A) and Sucrose (50, Group-B). In Group-A, SSC was provided at least 10 min before the procedure. In Group-B, 0.2 ml of oral Sucrose was provided 2 min before the procedure. Blinded assessment of Premature Infant Pain Profile (PIPP) score was done 30 s post-procedure using recorded videos.

RESULTS

Baseline variables were [Mean(SD)] gestational age [32.79(2.34) weeks], age [14.04(11.10) days] and birth weight [1.62(0.35) kilograms]. PIPP score was less in group- A vs. B but could not achieve statistical significance [Mean(SD): 7.74(2.43) vs. 8.1(2.82), p = 0.50 CI of the difference: (-1.40,0.68)].

CONCLUSIONS

SSC and Sucrose have comparable efficacy in managing pain in premature neonates.

Becoming a mother - Mothers' experience of Kangaroo Mother Care

OBJECTIVE

To describe mothers' experiences of providing their preterm infants with Kangaroo Mother Care (KMC).

STUDY DESIGN

A qualitative descriptive design.

SETTING

Two level III neonatal intensive care units (NICUs) in Sweden.

PARTICIPANTS

Thirteen mothers of preterm infants.

METHODS

The mothers were interviewed when their infant had reached a corrected age of 4 months ± 2 weeks. The interviews were recorded and transcribed and data were analyzed using qualitative content analysis.

RESULTS

The mothers described the skin-to-skin contact with, and closeness to, the preterm infant as something they valued, and involuntary physical separation as something they had to accept and adapt to. Providing the infant with breast milk by expressing and tube feeding was experienced as time-consuming and as impinging on the skin-to-skin contact.

CONCLUSION

Mothers want to stay close to their preterm infant. The NICU environment and staff can facilitate KMC by providing a private space for parents and infants, and enable mothers to breastfeed and express breast milk by giving them support based on science and proven experience.

The minimally effective dose of sucrose for procedural pain relief in neonates: a randomized controlled trial

Background

Orally administered sucrose is effective and safe in reducing pain intensity during single, tissue-damaging procedures in neonates, and is commonly recommended in neonatal pain guidelines. However, there is wide variability in sucrose doses examined in research, and more than a 20-fold variation across neonatal care settings. The aim of this study was to determine the minimally effective dose of 24% sucrose for reducing pain in hospitalized neonates undergoing a single skin-breaking heel lance procedure.

Methods

A total of 245 neonates from 4 Canadian tertiary neonatal intensive care units (NICUs), born between 24 and 42 weeks gestational age (GA), were prospectively randomized to receive one of three doses of 24% sucrose, plus non-nutritive sucking/pacifier, 2 min before a routine heel lance: 0.1 ml (Group 1; n = 81), 0.5 ml (Group 2; n = 81), or 1.0 ml (Group 3; n = 83). The primary outcome was pain intensity measured at 30 and 60 s following the heel lance, using the Premature Infant Pain Profile-Revised (PIPP-R). The secondary outcome was the incidence of adverse events. Analysis of covariance models, adjusting for GA and study site examined between group differences in pain intensity across intervention groups.

Results

There was no difference in mean pain intensity PIPP-R scores between treatment groups at 30 s (P = .97) and 60 s (P = .93); however, pain was not fully eliminated during the heel lance procedure. There were 5 reported adverse events among 5/245 (2.0%) neonates, with no significant differences in the proportion of events by sucrose dose (P = .62). All events resolved spontaneously without medical intervention.

Conclusions

The minimally effective dose of 24% sucrose required to treat pain associated with a single heel lance in neonates was 0.1 ml. Further evaluation regarding the sustained effectiveness of this dose in reducing pain intensity in neonates for repeated painful procedures is warranted.

Trial registration

ClinicalTrials.gov: NCT02134873. Date: May 5, 2014 (retrospectively registered).

The Neonatal Microbiome: Implications for Neonatal Intensive Care Unit Nurses

Nursing care of the neonate in the neonatal intensive care unit (NICU) is complex, due in large part to various physiological challenges. A newer and less well-known physiological consideration is the neonatal microbiome, the community of microorganisms, both helpful and harmful, that inhabit the human body. The neonatal microbiome is influenced by the maternal microbiome, mode of infant birth, and various aspects of NICU care such as feeding choice and use of antibiotics. The composition and diversity of the microbiome is thought to influence key health outcomes including development of necrotizing enterocolitis, late-onset sepsis, altered physical growth, and poor neurodevelopment. Nurses in the NICU play a key role in managing care that can positively influence the microbiome to promote more optimal health outcomes in this vulnerable population of newborns.

Acupuncture in the neonatal intensive care unit-using ancient medicine to help today's babies: a review

Acupuncture has been used for thousands of years in Eastern medicine for a variety of conditions and illnesses, including pain. Neonatal intensive care, on the other hand, is a relatively new branch of medicine that has emerged as the pivotal influence in increasing survival of critically ill newborn infants only within the last 50 years. Unfortunately, pain is an inevitable part of treatment in a neonatal intensive care unit (NICU). The control and prevention of pain remains a major issue for clinicians despite recognition and understanding of the myriad of short- and long-term problems that are associated with both pain and its treatment within the NICU environment. In this review, we examine the potential role of acupuncture to decrease and treat pain in babies requiring neonatal intensive care and discuss future therapeutic and research implications for the use of this ancient therapy within the modern environment of the NICU.

Postoperative Immobilization and Pain Management After Repair of Bladder Exstrophy

Surgical repair of bladder exstrophy is an ongoing challenge for pediatric urologists. Postoperative immobilization is a mainstay of care to decrease tension on the repair site and is often utilized in conjunction with pelvic osteotomies performed in the same operative setting by pediatric orthopedic surgeons. Multiple pelvic immobilization techniques have been developed in conjunction with repair techniques including special techniques for neonates. The most commonly utilized techniques for pelvic immobilization are Buck's and Bryant's traction and spica casting. A multimodal pain management approach is critical with pelvic immobilization to minimize postoperative pain and anxiety associated with reconstructive surgery at a young age.

What is the Best Pain Management During Gastric Tube Insertion for Infants Aged 0-12months: A Systematic Review

PROBLEM

Synthesized evidence on the effectiveness of pain management for nasogastric tube (NGT) and orogastric tube (OGT) insertions in infants is lacking. This paper is a systematic review of the effectiveness of pain management for gastric tube (GT) insertion in infants.

ELIGIBILITY CRITERIA

Randomized control trial (RCT) or quasi-experimental studies published up to April 2016, on pain management strategies during GT insertions (either NGT or OGT) in infants up to 12months of age. Databases searched included seven English databases and three Chinese databases.

RESULTS

Six English studies out of 1236 screened met the eligibility criteria and were included in the review. Two studied OGT insertion and four studies focused on NGT insertion. All six studies evaluated oral sweet solutions (24%-30% sucrose and 25% glucose) compared to placebo (water) or no treatment and all focused on newborn infants. Data from four studies which used the Premature Infant Pain Profile (PIPP) were pooled for meta-analysis. Results showed a significant reduction in PIPP scores during or immediately after the procedure for sweet solution interventions (MD=-2.18, 95% CI (-3.86, -0.51), P=0.01), compared to no intervention or placebo.

CONCLUSIONS

Small volumes of oral sweet solutions reduce pain during GT insertion procedure in newborn infants.

IMPLICATIONS

Oral sweet solutions can be recommended before GT insertion for newborns in clinical practice. Further studies determining the effect of sweet solution beyond the newborn period, different concentrations of sweet solution and comparison with other pain management strategies are warranted. Systematic review registration number: CRD42016038535. http://www.crd.york.ac.uk/prospero/.

Skin-to-Skin Contact Facilitates More Equal Parenthood - A Qualitative Study From Fathers' Perspective

DESIGN AND METHODS

A descriptive design was used where 20 fathers of premature infants were interviewed using a semi-structured interview-guide. The guide contained the following five topics: the fathers' feelings about and experiences of using skin-to-skin contact (SSC), the physical environment at the Neonatal Intensive Care unit, staff attitudes, and whether SSC had any impact on the relationship with their partner and other children in the family. The interviews were analyzed using directed qualitative content analysis and the results compared with those of a qualitative systematic review by Anderzén-Carlsson and colleagues.

RESULTS

The result shows that the fathers' overall experience of SSC was positive and as in the aforementioned review, they described experiences that were both gratifying and challenging. They felt more included and just as important as the mother because SSC and the demands placed on them by the premature birth helped them to achieve more equal parenthood.

CONCLUSION

The fathers' overall experiences of SSC were positive as they felt included in their infants' care and just as important as the mothers. To a great degree the theoretical model tested was supported, although some weaknesses and differences were identified.

PRACTICAL IMPLICATIONS

It is important to include fathers in neonatal care and recognize that they feel equally important as mothers in caring for premature infants.

Skin-to-skin care for procedural pain in neonates

BACKGROUND

Skin-to-skin care (SSC), often referred to as 'kangaroo care' (KC) due to its similarity with marsupial behaviour of ventral maternal-infant contact, is one non-pharmacological intervention for pain control in infants.

OBJECTIVES

The primary objectives were to determine the effect of SSC alone on pain from medical or nursing procedures in neonates compared to no intervention, sucrose or other analgesics, or additions to simple SSC such as rocking; and to determine the effects of the amount of SSC (duration in minutes), method of administration (e.g. who provided the SSC) of SSC in reducing pain from medical or nursing procedures in neonatesThe secondary objectives were to determine the safety of SSC care for relieving procedural pain in infants; and to compare the SSC effect in different postmenstrual age subgroups of infants.

SEARCH METHODS

For this update, we used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 1); MEDLINE via PubMed (1966 to 25 February 2016); Embase (1980 to 25 February 2016); and CINAHL (1982 to 25 February 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials.

SELECTION CRITERIA

Studies with randomisation or quasi-randomisation, double- or single-blinded, involving term infants (≥ 37 completed weeks' postmenstrual age (PMA) to a maximum of 44 weeks' PMA and preterm infants (< 37 completed weeks PMA) receiving SSC for painful procedures conducted by healthcare professionals.

DATA COLLECTION AND ANALYSIS

The main outcome measures were physiological or behavioural pain indicators and composite pain scores. A mean difference (MD) with 95% confidence interval (CI) using a fixed-effect model was reported for continuous outcome measures. We included variations on type of tissue-damaging procedure, provider of care, and duration of SSC.

MAIN RESULTS

Twenty-five studies (n = 2001 infants) were included. Nineteen studies (n = 1065) used heel lance as the painful procedure, one study combined venepuncture and heel stick (n = 50), three used intramuscular injection (n = 776), one used 'vaccination' (n = 60), and one used tape removal (n = 50). The studies were generally strong and had low or uncertain risk of bias. Blinding of the intervention was not possible, making them subject to high risk, depending on the method of scoring outcomes.Seventeen studies (n = 810) compared SSC to a no-treatment control. Although 15 studies measured heart rate during painful procedures, data from only five studies (n = 161) could be combined for a mean difference (MD) of -10.78 beats per minute (95% CI -13.63 to -7.93) favouring SSC. Meta-analysis of four studies (n = 120) showed no difference in heart rate following the painful procedure (MD 0.08, 95% CI -4.39 to 4.55). Two studies (n = 38) reported heart rate variability with no significant differences. Two studies (n = 101) in a meta-analysis on oxygen saturation at 30 and 60 seconds following the painful procedure did not show a difference. Duration of crying meta-analysis was performed on four studies (n = 133): two (n = 33) investigated response to heel lance (MD = -34.16, 95% CI -42.86 to -25.45), and two (n = 100) following IM injection (MD = -8.83, 95% CI -14.63 to -3.02), favouring SSC. Five studies, one consisting of two substudies (n = 267), used the Premature Infant Pain Profile (PIPP) as a primary outcome, which favoured SCC at 30 seconds (MD -3.21, 95% CI -3.94 to -2.47), at 60 seconds (3 studies; n = 156) (MD -1.64, 95% CI -2.86 to -0.43), and at 90 seconds (n = 156) (MD -1.28, 95% CI -2.53 to -0.04); but at 120 seconds there was no difference (n = 156) (MD 0.07, 95% CI -1.11 to 1.25). No studies on return of heart rate to baseline level, cortisol levels, and facial actions could be combined for meta-analysis findings.Eight studies compared SSC to another intervention with or without a no-treatment control. Two cross-over studies (n = 80) compared mother versus other provider (father, another female) on PIPP scores at 30, 60, 90, and 120 seconds with no significant difference. When SSC was compared to other interventions, there were not enough similar studies to pool results in an analysis. One study compared SSC (n = 640) with and without dextrose and found that the combination was most effective and that SSC alone was more effective than dextrose alone. Similarly, in another study SSC was more effective than oral glucose for heart rate (n = 95). SSC either in combination with breastfeeding or alone was favoured over a no-treatment control, but not different to breastfeeding. One study compared SSC alone and in combination with both sucrose and breastfeeding on heart rate (HR), NIPS scores, and crying time (n = 127). The combinations were more effective than SSC alone for NIPS and crying. Expressed breast milk was compared to SSC in one study (n = 50) and found both equally effective on PIPP scores. There were not enough participants with similar outcomes and painful procedures to compare age groups or duration of SSC. No adverse events were reported in any of the studies.

AUTHORS' CONCLUSIONS

SSC appears to be effective as measured by composite pain indicators with both physiological and behavioural indicators and, independently, using heart rate and crying time; and safe for a single painful procedure. Purely behavioural indicators tended to favour SSC but with facial actions there is greater possibility of observers not being blinded. Physiological indicators were mixed although the common measure of heart rate favoured SSC. Two studies compared mother-providers to others, with non-significant results. There was more heterogeneity in the studies with behavioural or composite outcomes. There is a need for replication studies that use similar, clearly defined outcomes. Studies examining optimal duration of SSC, gestational age groups, repeated use, and long-term effects of SSC are needed. Of interest would be to study synergistic effects of SSC with other interventions.

Defining Procedural Distress in the NICU and What Can Be Done About It

Procedural distress is a common occurrence in the NICU and is tied to attempts to support the life and development of vulnerable premature infants. We discuss the epidemiology of procedural distress and the potential negative consequences on infant neurodevelopment. We define procedural distress in the NICU and outline three approaches to limit or to reduce its detrimental effects including minimizing the number of procedures, instituting measures for developmentally supportive care, and using preemptively pharmacologic and nonpharmacologic analgesia. Despite the pervasiveness of procedural distress in the NICU, clinical and administrative measures are available to ameliorate possible harmful outcomes.

Value of Specialty Certification as a Kangaroo Caregiver

Kangaroo care (KC), also known as skin-to-skin contact, saves lives, but fewer than 50% of newborns and mothers in U.S. hospitals receive KC because of lack of knowledge and skill competency. Because nurses can increase knowledge and skill competency through a certification course, the value of certification as a kangaroo caregiver and administrative incentives for certification as a kangaroo caregiver were evaluated in 71 neonatal intensive care and maternal-newborn unit nurses who completed an electronic questionnaire and the Perceived Value of Certification Tool. Nurses highly valued their KC certification, agreeing with 17 of 18 positive value statements. KC certification increased salary for a few, but institution-based incentives for KC certification are still limited and recognition of KC certification is needed.

Kangaroo Mother Care 1: Alleviation of Physiological Problems in Premature Infants

Kangaroo mother care (KMC) involves placing the newborn infant into prolonged and continuous skin-to-skin contact with the mother as soon as possible after birth, exclusive breastfeeding, early discharge from the health facility, and supportive follow-up at home. Claimed benefits of KMC as an aid to the clinical mitigation of some detrimental features of prematurity need to be evidence based. This article, the first of two, provides an overview of the impact of prematurity on those features of neonates to which KMC may be directed. Specifically, the mitigation of some cardiorespiratory, neurophysiological, sensory, gastrointestinal, musculoskeletal, renal, metabolic, and immunological impacts are outlined. Relevant neurobehavioral, psychosocial, sociocultural, and economic perspectives are briefly reviewed in the companion article. These two articles provide scientific support for a wider upscaling of KMC education and its cautious use in physiologically stable preterm infants.

Early skin-to-skin contact for mothers and their healthy newborn infants

BACKGROUND

Mother-infant separation post birth is common. In standard hospital care, newborn infants are held wrapped or dressed in their mother's arms, placed in open cribs or under radiant warmers. Skin-to-skin contact (SSC) begins ideally at birth and should last continually until the end of the first breastfeeding. SSC involves placing the dried, naked baby prone on the mother's bare chest, often covered with a warm blanket. According to mammalian neuroscience, the intimate contact inherent in this place (habitat) evokes neuro-behaviors ensuring fulfillment of basic biological needs. This time frame immediately post birth may represent a 'sensitive period' for programming future physiology and behavior.

OBJECTIVES

To assess the effects of immediate or early SSC for healthy newborn infants compared to standard contact on establishment and maintenance of breastfeeding and infant physiology.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (17 December 2015), made personal contact with trialists, consulted the bibliography on kangaroo mother care (KMC) maintained by Dr Susan Ludington, and reviewed reference lists of retrieved studies.

SELECTION CRITERIA

Randomized controlled trials that compared immediate or early SSC with usual hospital care.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

We included 46 trials with 3850 women and their infants; 38 trials with 3472 women and infants contributed data to our analyses. Trials took place in 21 countries, and most recruited small samples (just 12 trials randomized more than 100 women). Eight trials included women who had SSC after cesarean birth. All infants recruited to trials were healthy, and the majority were full term. Six trials studied late preterm infants (greater than 35 weeks' gestation). No included trial met all criteria for good quality with respect to methodology and reporting; no trial was successfully blinded, and all analyses were imprecise due to small sample size. Many analyses had statistical heterogeneity due to considerable differences between SSC and standard care control groups. Results for womenSSC women were more likely than women with standard contact to be breastfeeding at one to four months post birth, though there was some uncertainty in this estimate due to risks of bias in included trials (average risk ratio (RR) 1.24, 95% confidence interval (CI) 1.07 to 1.43; participants = 887; studies = 14; I² = 41%; GRADE: moderate quality). SSC women also breast fed their infants longer, though data were limited (mean difference (MD) 64 days, 95% CI 37.96 to 89.50; participants = 264; studies = six; GRADE:low quality); this result was from a sensitivity analysis excluding one trial contributing all of the heterogeneity in the primary analysis. SSC women were probably more likely to exclusively breast feed from hospital discharge to one month post birth and from six weeks to six months post birth, though both analyses had substantial heterogeneity (from discharge average RR 1.30, 95% CI 1.12 to 1.49; participants = 711; studies = six; I² = 44%; GRADE: moderate quality; from six weeks average RR 1.50, 95% CI 1.18 to 1.90; participants = 640; studies = seven; I² = 62%; GRADE: moderate quality).Women in the SCC group had higher mean scores for breastfeeding effectiveness, with moderate heterogeneity (IBFAT (Infant Breastfeeding Assessment Tool) score MD 2.28, 95% CI 1.41 to 3.15; participants = 384; studies = four; I² = 41%). SSC infants were more likely to breast feed successfully during their first feed, with high heterogeneity (average RR 1.32, 95% CI 1.04 to 1.67; participants = 575; studies = five; I² = 85%). Results for infantsSSC infants had higher SCRIP (stability of the cardio-respiratory system) scores overall, suggesting better stabilization on three physiological parameters. However, there were few infants, and the clinical significance of the test was unclear because trialists reported averages of multiple time points (standardized mean difference (SMD) 1.24, 95% CI 0.76 to 1.72; participants = 81; studies = two; GRADE low quality). SSC infants had higher blood glucose levels (MD 10.49, 95% CI 8.39 to 12.59; participants = 144; studies = three; GRADE: low quality), but similar temperature to infants in standard care (MD 0.30 degree Celcius (°C) 95% CI 0.13 °C to 0.47 °C; participants = 558; studies = six; I² = 88%; GRADE: low quality). Women and infants after cesarean birthWomen practicing SSC after cesarean birth were probably more likely to breast feed one to four months post birth and to breast feed successfully (IBFAT score), but analyses were based on just two trials and few women. Evidence was insufficient to determine whether SSC could improve breastfeeding at other times after cesarean. Single trials contributed to infant respiratory rate, maternal pain and maternal state anxiety with no power to detect group differences. SubgroupsWe found no differences for any outcome when we compared times of initiation (immediate less than 10 minutes post birth versus early 10 minutes or more post birth) or lengths of contact time (60 minutes or less contact versus more than 60 minutes contact).

AUTHORS' CONCLUSIONS

Evidence supports the use of SSC to promote breastfeeding. Studies with larger sample sizes are necessary to confirm physiological benefit for infants during transition to extra-uterine life and to establish possible dose-response effects and optimal initiation time. Methodological quality of trials remains problematic, and small trials reporting different outcomes with different scales and limited data limit our confidence in the benefits of SSC for infants. Our review included only healthy infants, which limits the range of physiological parameters observed and makes their interpretation difficult.

Breastfeeding for procedural pain in infants beyond the neonatal period

BACKGROUND

Randomised controlled trials (RCTs) show that breastfeeding newborn infants during painful procedures reduces pain. Mechanisms are considered to be multifactorial and include sucking, skin-to-skin contact, warmth, rocking, sound and smell of the mother, and possibly endogenous opiates present in the breast milk.

OBJECTIVES

To determine the effect of breastfeeding on procedural pain in infants beyond the neonatal period (first 28 days of life) up to one year of age compared to no intervention, placebo, parental holding, skin-to-skin contact, expressed breast milk, formula milk, bottle feeding, sweet-tasting solutions (e.g. sucrose or glucose), distraction, or other interventions.

SEARCH METHODS

We searched the following databases to 18 February 2016: the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), MEDLINE including In-Process & Other Non-Indexed Citations (OVID), Embase (OVID), PsycINFO (OVID), and CINAHL (EBSCO); the metaRegister of Controlled Trials (mRCT), ClinicalTrials.gov (clinicaltrials.gov), and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) (apps.who.int/trialsearch/) for ongoing trials.

SELECTION CRITERIA

We included RCTs and quasi-RCTs involving infants aged 28 days postnatal to 12 months and receiving breastfeeding while undergoing a painful procedure. Comparators included, but were not limited to, oral administration of water, sweet-tasting solutions, expressed breast or formula milk, no intervention, use of pacifiers, positioning, cuddling, distraction, topical anaesthetics, and skin-to-skin care. Procedures included, but were not limited to: subcutaneous or intramuscular injection, venipuncture, intravenous line insertion, heel lance, and finger lance. We applied no language restrictions.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently considered trials for inclusion in the review, assessed risk of bias, and extracted data. The main outcome measures were behavioural or physiological indicators and composite pain scores, as well as other clinically important outcomes reported by the authors of included studies. We pooled data for the most comparable outcomes and where data from at least two studies could be included. We used mean difference (MD) with 95% confidence interval (CI), employing a random-effects model for continuous outcomes measured on the same scales. For continuous outcomes measured on different scales, we pooled standardised mean differences (SMDs) and associated 95% CIs. For dichotomous outcomes, we planned to pool events between groups across studies using risk ratios (RRs) and 95% CIs. However, as insufficient studies reported dichotomous outcomes, we did not pool such events. We assessed the evidence using GRADE and created a 'Summary of findings' table.

MAIN RESULTS

We included 10 studies with a total of 1066 infants. All studies were conducted during early childhood immunisation. As the breastfeeding intervention cannot be blinded, we rated all studies as being at high risk of bias for blinding of participants and personnel. We assessed nine studies as being at low risk of bias for incomplete outcome data. In addition, we rated nine studies as high risk for blinding of outcome assessment. We scored risk of bias related to random sequence generation, allocation concealment, and selective reporting as unclear for the majority of the studies due to lack of information.Our primary outcome was pain. Breastfeeding reduced behavioural pain responses (cry time and pain scores) during vaccination compared to no treatment, oral water, and other interventions such as cuddling, oral glucose, topical anaesthetic, massage, and vapocoolant. Breastfeeding did not consistently reduce changes in physiological indicators, such as heart rate. We pooled data for duration of cry from six studies (n = 547 infants). Breastfeeding compared to water or no treatment resulted in a 38-second reduction in cry time (MD -38, 95% CI -50 to -26; P < 0.00001). The quality of the evidence according to GRADE for this outcome was moderate, as most infants were 6 months or younger, and outcomes may be different for infants during their 12-month immunisation. We pooled data for pain scores from five studies (n = 310 infants). Breastfeeding was associated with a 1.7-point reduction in standardised pain scores (SMD -1.7, 95% CI -2.2 to -1.3); we considered this evidence to be of moderate quality as data were primarily from infants younger than 6 months of age. We could pool heart rate data following injections for only two studies (n = 186); we considered this evidence to be of low quality due to insufficient data. There were no differences between breastfeeding and control (MD -3.6, -23 to 16).Four of the 10 studies had more than two study arms. Breastfeeding was more effective in reducing crying duration or pain scores during vaccination compared to: 25% dextrose and topical anaesthetic cream (EMLA), vapocoolant, maternal cuddling, and massage.No included studies reported adverse events.

AUTHORS' CONCLUSIONS

We conclude, based on the 10 studies included in this review, that breastfeeding may help reduce pain during vaccination for infants beyond the neonatal period. Breastfeeding consistently reduced behavioural responses of cry duration and composite pain scores during and following vaccinations. However, there was no evidence that breastfeeding had an effect on physiological responses. No studies included in this review involved populations of hospitalised infants undergoing other skin-breaking procedures. Although it may be possible to extrapolate the review results to this population, further studies of efficacy, feasibility, and acceptability in this population are warranted.

Affective touch and attachment style modulate pain: a laser-evoked potentials study

Affective touch and cutaneous pain are two sub-modalities of interoception with contrasting affective qualities (pleasantness/unpleasantness) and social meanings (care/harm), yet their direct relationship has not been investigated. In 50 women, taking into account individual attachment styles, we assessed the role of affective touch and particularly the contribution of the C tactile (CT) system in subjective and electrophysiological responses to noxious skin stimulation, namely N1 and N2-P2 laser-evoked potentials. When pleasant, slow (versus fast) velocity touch was administered to the (non-CT-containing) palm of the hand, higher attachment anxiety predicted increased subjective pain ratings, in the same direction as changes in N2 amplitude. By contrast, when pleasant touch was administered to CT-containing skin of the arm, higher attachment anxiety predicted attenuated N1 and N2 amplitudes. Higher attachment avoidance predicted opposite results. Thus, CT-based affective touch can modulate pain in early and late processing stages (N1 and N2 components), with the direction of effects depending on attachment style. Affective touch not involving the CT system seems to affect predominately the conscious perception of pain, possibly reflecting socio-cognitive factors further up the neurocognitive hierarchy. Affective touch may thus convey information about available social resources and gate pain responses depending on individual expectations of social support.

This article is part of the themed issue ‘Interoception beyond homeostasis: affect, cognition and mental health’.

"It Don't Mean a Thing if It Ain't Got that Swing"- an Alternative Concept for Understanding the Evolution of Dance and Music in Human Beings

The functions of dance and music in human evolution are a mystery. Current research on the evolution of music has mainly focused on its melodic attribute which would have evolved alongside (proto-)language. Instead, we propose an alternative conceptual framework which focuses on the co-evolution of rhythm and dance (R&D) as intertwined aspects of a multimodal phenomenon characterized by the unity of action and perception. Reviewing the current literature from this viewpoint we propose the hypothesis that R&D have co-evolved long before other musical attributes and (proto-)language. Our view is supported by increasing experimental evidence particularly in infants and children: beat is perceived and anticipated already by newborns and rhythm perception depends on body movement. Infants and toddlers spontaneously move to a rhythm irrespective of their cultural background. The impulse to dance may have been prepared by the susceptibility of infants to be soothed by rocking. Conceivable evolutionary functions of R&D include sexual attraction and transmission of mating signals. Social functions include bonding, synchronization of many individuals, appeasement of hostile individuals, and pre- and extra-verbal communication enabling embodied individual and collective memorizing. In many cultures R&D are used for entering trance, a base for shamanism and early religions. Individual benefits of R&D include improvement of body coordination, as well as painkilling, anti-depressive, and anti-boredom effects. Rhythm most likely paved the way for human speech as supported by studies confirming the overlaps between cognitive and neural resources recruited for language and rhythm. In addition, dance encompasses visual and gestural communication. In future studies attention should be paid to which attribute of music is focused on and that the close mutual relation between R&D is taken into account. The possible evolutionary functions of dance deserve more attention.

Translating Neurodevelopmental Care Policies Into Practice: The Experience of Neonatal ICUs in France-The EPIPAGE-2 Cohort Study

OBJECTIVES

To describe the implementation of neurodevelopmental care for newborn preterm infants in neonatal ICUs in France in 2011, analyze changes since 2004, and investigate factors associated with practice.

DESIGN

Prospective national cohort study of all births before 32 weeks of gestation.

SETTING

Twenty-five French regions.

PARTICIPANTS

All neonatal ICUs (n = 66); neonates surviving at discharge (n = 3,005).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Neurodevelopmental care policies and practices were assessed by structured questionnaires. Proportions of neonates initiating kangaroo care during the first week of life and those whose mothers expressed breast milk were measured as neurodevelopmental care practices. Multilevel logistic regression analyses were used to investigate relationships between kangaroo care or breast-feeding practices and unit policies, taking into account potential confounders. Free visiting policies, bed availability for parents, and kangaroo care encouragement significantly improved between 2004 and 2011 but with large variabilities between units. Kangaroo care initiation varied from 39% for neonates in the most restrictive units to 68% in less restrictive ones (p < 0.001). Individual factors associated with kangaroo care initiation were gestational age (odds ratio, 5.79; 95% CI, 4.49-7.48 for babies born at 27-31 wk compared with babies born at 23-26 wk) and, to a lesser extent, single pregnancy, birthweight above the 10th centile, and mother's employment before pregnancy. At unit level, policies and training in neurodevelopmental care significantly influenced kangaroo care initiation (odds ratio, 3.5; 95% CI, 1.8-7.0 for Newborn Individualized Developmental Care and Assessment Program implementation compared with no training). Breast milk expression by mothers was greater in units with full-time availability professionals trained for breast-feeding support (60% vs 73%; p < 0.0001).

CONCLUSIONS

Dissemination of neurodevelopmental practices occurred between 2004 and 2011, but large variabilities between units persist. Practices increased in units with supportive policies. Specific neurodevelopmental care training with multifaceted interventions strengthened the implementation of policies.

A feasibility and efficacy randomised controlled trial of swaddling for controlling procedural pain in preterm infants

AIMS AND OBJECTIVES

This study aimed to investigate the feasibility and efficacy of swaddling to control procedural pain among preterm infants.

BACKGROUND

Swaddling has been recommended for controlling neonatal pain. However, the feasibility for use is uncertain and insufficient evidence is available among preterm infants.

DESIGN

A two-arm randomised controlled trial with repeated measures.

METHOD

The study was conducted in a 21-bed neonatal intensive care unit of a regional hospital in Hong Kong. Preterm infants who required heelstick procedure were eligible. Fifty-four preterm infants between 30-37 gestational weeks were randomly assigned to swaddling (n = 27) and control (standard care, n = 27) groups. Pain assessment was performed pre, during, immediate, two, four, six and eight minutes after heelstick procedure using the Premature Infant Pain Profile.

RESULTS

The mean Premature Infant Pain Profile scores were significantly reduced in the intervention group compared to the control group during, immediate, two, four, and six minutes after the heelstick procedure. The mean changes of heart rate and oxygen saturation in the intervention group were significantly lower than that of the control group at all measured time points. Notably, the swaddled infants quickly resumed to the baseline level at two minutes whereas the control group reached the stable state at an extended period of six minutes.

CONCLUSION

The findings show that swaddling is feasible and efficacious in controlling pain for heelstick procedure among preterm infants. No adverse effects were observed.

RELEVANCE TO CLINICAL PRACTICE

This article presents the feasibility and efficacy of swaddling as a non-pharmacological and non-invasive intervention to relieve pain during the heelstick procedures among preterm infants. Swaddling can contribute to control minor procedural pain in neonates as one of the simple, safe, cost effective, humanistic and natural analgesia alternatives.

Kangaroo mother care to reduce morbidity and mortality in low birthweight infants

BACKGROUND

Kangaroo mother care (KMC), originally defined as skin-to-skin contact between a mother and her newborn, frequent and exclusive or nearly exclusive breastfeeding, and early discharge from hospital, has been proposed as an alternative to conventional neonatal care for low birthweight (LBW) infants.

OBJECTIVES

To determine whether evidence is available to support the use of KMC in LBW infants as an alternative to conventional neonatal care before or after the initial period of stabilization with conventional care, and to assess beneficial and adverse effects.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches in CENTRAL (Cochrane Central Register of Controlled Trials; 2016, Issue 6), MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), LILACS (Latin American and Caribbean Health Science Information database), and POPLINE (Population Information Online) databases (all from inception to June 30, 2016), as well as the WHO (World Health Organization) Trial Registration Data Set (up to June 30, 2016). In addition, we searched the web page of the Kangaroo Foundation, conference and symposia proceedings on KMC, and Google Scholar.

SELECTION CRITERIA

Randomized controlled trials comparing KMC versus conventional neonatal care, or early-onset KMC versus late-onset KMC, in LBW infants.

DATA COLLECTION AND ANALYSIS

Data collection and analysis were performed according to the methods of the Cochrane Neonatal Review Group.

MAIN RESULTS

Twenty-one studies, including 3042 infants, fulfilled inclusion criteria. Nineteen studies evaluated KMC in LBW infants after stabilization, one evaluated KMC in LBW infants before stabilization, and one compared early-onset KMC with late-onset KMC in relatively stable LBW infants. Sixteen studies evaluated intermittent KMC, and five evaluated continuous KMC. KMC versus conventional neonatal care: At discharge or 40 to 41 weeks' postmenstrual age, KMC was associated with a statistically significant reduction in the risk of mortality (risk ratio [RR] 0.60, 95% confidence interval [CI] 0.39 to 0.92; eight trials, 1736 infants), nosocomial infection/sepsis (RR 0.35, 95% CI 0.22 to 0.54; five trials, 1239 infants), and hypothermia (RR 0.28, 95% CI 0.16 to 0.49; nine trials, 989 infants; moderate-quality evidence). At latest follow-up, KMC was associated with a significantly decreased risk of mortality (RR 0.67, 95% CI 0.48 to 0.95; 12 trials, 2293 infants; moderate-quality evidence) and severe infection/sepsis (RR 0.50, 95% CI 0.36 to 0.69; eight trials, 1463 infants; moderate-quality evidence). Moreover, KMC was found to increase weight gain (mean difference [MD] 4.1 g/d, 95% CI 2.3 to 5.9; 11 trials, 1198 infants; moderate-quality evidence), length gain (MD 0.21 cm/week, 95% CI 0.03 to 0.38; three trials, 377 infants) and head circumference gain (MD 0.14 cm/week, 95% CI 0.06 to 0.22; four trials, 495 infants) at latest follow-up, exclusive breastfeeding at discharge or 40 to 41 weeks' postmenstrual age (RR 1.16, 95% CI 1.07 to 1.25; six studies, 1453 mothers) and at one to three months' follow-up (RR 1.20, 95% CI 1.01 to 1.43; five studies, 600 mothers), any (exclusive or partial) breastfeeding at discharge or at 40 to 41 weeks' postmenstrual age (RR 1.20, 95% CI 1.07 to 1.34; 10 studies, 1696 mothers; moderate-quality evidence) and at one to three months' follow-up (RR 1.17, 95% CI 1.05 to 1.31; nine studies, 1394 mothers; low-quality evidence), and some measures of mother-infant attachment and home environment. No statistically significant differences were found between KMC infants and controls in Griffith quotients for psychomotor development at 12 months' corrected age (low-quality evidence). Sensitivity analysis suggested that inclusion of studies with high risk of bias did not affect the general direction of findings nor the size of the treatment effect for main outcomes. Early-onset KMC versus late-onset KMC in relatively stable infants: One trial compared early-onset continuous KMC (within 24 hours post birth) versus late-onset continuous KMC (after 24 hours post birth) in 73 relatively stable LBW infants. Investigators reported no significant differences between the two study groups in mortality, morbidity, severe infection, hypothermia, breastfeeding, and nutritional indicators. Early-onset KMC was associated with a statistically significant reduction in length of hospital stay (MD 0.9 days, 95% CI 0.6 to 1.2).

AUTHORS' CONCLUSIONS

Evidence from this updated review supports the use of KMC in LBW infants as an alternative to conventional neonatal care, mainly in resource-limited settings. Further information is required concerning the effectiveness and safety of early-onset continuous KMC in unstabilized or relatively stabilized LBW infants, as well as long-term neurodevelopmental outcomes and costs of care.