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

Nonpharmacological Interventions to Mitigate Procedural Pain in the NICU: An Integrative Review

BACKGROUND

Small infants experience a myriad of stimuli while in the Neonatal Intensive Care Unit (NICU), with many being painful or stressful experiences, although medically necessary.

PURPOSE

To determine what is known about nonpharmacological developmental care interventions used in the NICU to mitigate procedural pain of infants born under 32 weeks gestation.

SEARCH/STRATEGY

Five electronic databases were searched: Medline, CINAHL, Scopus, Embase and the Cochrane Library. The inclusion criteria were as follows: experimental and nonexperimental studies from all publication years with infants born at less than 32 weeks gestational age; peer-reviewed research articles studying nonpharmacological interventions such as skin-to-skin care, facilitated tucking, nonnutritive sucking, hand hugs, and swaddling; and English language articles. Our search yielded 1435 articles. After the elimination of 736 duplicates, a further 570 were deemed irrelevant based on their abstract/titles. Then, 124 full-text articles were analyzed with our inclusion and exclusion criteria.

FINDINGS

Twenty-seven studies were reviewed. Sucrose, facilitated tucking, pacifier, skin-to-skin care, and human milk appeared to lessen pain experienced during heel sticks, suctioning, nasogastric tube insertions, and echocardiograms. All nonpharmacological interventions failed to prove efficacious to adequately manage pain during retinopathy of prematurity (ROP) examinations.

IMPLICATIONS FOR PRACTICE

Evidence review demonstrates that healthcare practitioners should use nonpharmacological measures to help prevent pain from day-to-day procedures in the NICU including heel sticks, nasogastric tube insertions, suctioning, echocardiograms, and subcutaneous injections.

IMPLICATIONS FOR RESEARCH

Future research is necessary to better understand and measure how pain is manifested by very small premature infants. Specific research on mitigating the pain of examinations for retinopathy of prematurity is also needed.

A systematic review and multivariate meta-analysis of the physical and mental health benefits of touch interventions

Receiving touch is of critical importance, as many studies have shown that touch promotes mental and physical well-being. We conducted a pre-registered (PROSPERO: CRD42022304281) systematic review and multilevel meta-analysis encompassing 137 studies in the meta-analysis and 75 additional studies in the systematic review (n = 12,966 individuals, search via Google Scholar, PubMed and Web of Science until 1 October 2022) to identify critical factors moderating touch intervention efficacy. Included studies always featured a touch versus no touch control intervention with diverse health outcomes as dependent variables. Risk of bias was assessed via small study, randomization, sequencing, performance and attrition bias. Touch interventions were especially effective in regulating cortisol levels (Hedges' g = 0.78, 95% confidence interval (CI) 0.24 to 1.31) and increasing weight (0.65, 95% CI 0.37 to 0.94) in newborns as well as in reducing pain (0.69, 95% CI 0.48 to 0.89), feelings of depression (0.59, 95% CI 0.40 to 0.78) and state (0.64, 95% CI 0.44 to 0.84) or trait anxiety (0.59, 95% CI 0.40 to 0.77) for adults. Comparing touch interventions involving objects or robots resulted in similar physical (0.56, 95% CI 0.24 to 0.88 versus 0.51, 95% CI 0.38 to 0.64) but lower mental health benefits (0.34, 95% CI 0.19 to 0.49 versus 0.58, 95% CI 0.43 to 0.73). Adult clinical cohorts profited more strongly in mental health domains compared with healthy individuals (0.63, 95% CI 0.46 to 0.80 versus 0.37, 95% CI 0.20 to 0.55). We found no difference in health benefits in adults when comparing touch applied by a familiar person or a health care professional (0.51, 95% CI 0.29 to 0.73 versus 0.50, 95% CI 0.38 to 0.61), but parental touch was more beneficial in newborns (0.69, 95% CI 0.50 to 0.88 versus 0.39, 95% CI 0.18 to 0.61). Small but significant small study bias and the impossibility to blind experimental conditions need to be considered. Leveraging factors that influence touch intervention efficacy will help maximize the benefits of future interventions and focus research in this field.

COMFORTneo scale in preterm infants during live performed music therapy-Difference between close physical contact and hand touch contact

There is evidence that music therapy combined with physical contact to parents stabilizes the vital signs of hospitalized preterm infants. Yet, there is no evidence for the difference between simple contact by touching the infant in the incubator or cod, or close physical contact during music therapy sessions (MT). Behavioral effects of the various forms of attention toward the infant during therapy need to be elucidated. Our study aimed to quantify the effects of hand touch contact (HTC) and close physical contact (CPC) during live performed MT in preterm infants regardless of gestational age on behavioral state (assessed via COMFORTneo scale) and vital signs. A maximum of ten live music therapy sessions were delivered three to four times a week until hospital discharge to 50 stable infants. Pre-, during- and post-therapy heart rates, respiratory rates, oxygen saturations and COMFORTneo scores were recorded for each session. A total of 486 sessions was performed with 243 sessions using HTC and CPC each. The mean gestational age was 33 + 3 weeks, with 27 (54%) infants being male. We observed lower COMFORTneo scores, heart and respiratory rates and higher oxygen saturation during and after live performed music therapy independent of the kind of physical contact than before therapy. While pre-therapy values were better in the CPC group for all four variables, a higher mean response on COMFORTneo scale and vital signs was observed for HTC (COMFORTneo score -5.5, heart rate -12.4 beats per min., respiratory rate -8.9 breaths per min, oxygen saturation + 1.5%) compared to CPC (COMFORTneo score -4.6, heart rate -9.6 beats per min., respiratory rate -7.0 breaths per min, oxygen saturation + 1.1%). Nonetheless, post-therapy values were better for all four measures in the CPC group. Regression modeling with correction for individual responses within each patient also yielded attenuated effects of MT in the CPC group compared to HTC, likely caused by the improved pre-therapy values. Live performed music therapy benefits preterm infants' vital signs and behavioral state. During CPC with a parent, the absolute therapeutic effect is attenuated but resulting post-therapy values are nonetheless better for both the COMFORTneo scale and vital signs.

Non-pharmacological management of infant and young child procedural pain

BACKGROUND

Despite evidence of the long-term implications of unrelieved pain during infancy, it is evident that infant pain is still under-managed and unmanaged. Inadequately managed pain in infancy, a period of exponential development, can have implications across the lifespan. Therefore, a comprehensive and systematic review of pain management strategies is integral to appropriate infant pain management. This is an update of a previously published review update in the Cochrane Database of Systematic Reviews (2015, Issue 12) of the same title.

OBJECTIVES

To assess the efficacy and adverse events of non-pharmacological interventions for infant and child (aged up to three years) acute pain, excluding kangaroo care, sucrose, breastfeeding/breast milk, and music.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE-Ovid platform, EMBASE-OVID platform, PsycINFO-OVID platform, CINAHL-EBSCO platform and trial registration websites (ClinicalTrials.gov; International Clinical Trials Registry Platform) (March 2015 to October 2020). An update search was completed in July 2022, but studies identified at this point were added to 'Awaiting classification' for a future update.  We also searched reference lists and contacted researchers via electronic list-serves.  We incorporated 76 new studies into the review.  SELECTION CRITERIA: Participants included infants from birth to three years in randomised controlled trials (RCTs) or cross-over RCTs that had a no-treatment control comparison. Studies were eligible for inclusion in the analysis if they compared a non-pharmacological pain management strategy to a no-treatment control group (15 different strategies). In addition, we also analysed studies when the unique effect of adding a non-pharmacological pain management strategy onto another pain management strategy could be assessed (i.e. additive effects on a sweet solution, non-nutritive sucking, or swaddling) (three strategies). The eligible control groups for these additive studies were sweet solution only, non-nutritive sucking only, or swaddling only, respectively. Finally, we qualitatively described six interventions that met the eligibility criteria for inclusion in the review, but not in the analysis.  DATA COLLECTION AND ANALYSIS: The outcomes assessed in the review were pain response (reactivity and regulation) and adverse events. The level of certainty in the evidence and risk of bias were based on the Cochrane risk of bias tool and the GRADE approach. We analysed the standardised mean difference (SMD) using the generic inverse variance method to determine effect sizes.  MAIN RESULTS: We included total of 138 studies (11,058 participants), which includes an additional 76 new studies for this update. Of these 138 studies, we analysed 115 (9048 participants) and described 23 (2010 participants) qualitatively. We described qualitatively studies that could not be meta-analysed due to being the only studies in their category or statistical reporting issues. We report the results of the 138 included studies here. An SMD effect size of 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect. The thresholds for the I2 interpretation were established as follows: not important (0% to 40%); moderate heterogeneity (30% to 60%); substantial heterogeneity (50% to 90%); considerable heterogeneity (75% to 100%). The most commonly studied acute procedures were heel sticks (63 studies) and needlestick procedures for the purposes of vaccines/vitamins (35 studies). We judged most studies to have high risk of bias (103 out of 138), with the most common methodological concerns relating to blinding of personnel and outcome assessors. Pain responses were examined during two separate pain phases: pain reactivity (within the first 30 seconds after the acutely painful stimulus) and immediate pain regulation (after the first 30 seconds following the acutely painful stimulus). We report below the strategies with the strongest evidence base for each age group. In preterm born neonates, non-nutritive sucking may reduce pain reactivity (SMD -0.57, 95% confidence interval (CI) -1.03 to -0.11, moderate effect; I2 = 93%, considerable heterogeneity) and improve immediate pain regulation (SMD -0.61, 95% CI -0.95 to -0.27, moderate effect; I2 = 81%, considerable heterogeneity), based on very low-certainty evidence. Facilitated tucking may also reduce pain reactivity (SMD -1.01, 95% CI -1.44 to -0.58, large effect; I2 = 93%, considerable heterogeneity) and improve immediate pain regulation (SMD -0.59, 95% CI -0.92 to -0.26, moderate effect; I2 = 87%, considerable heterogeneity); however, this is also based on very low-certainty evidence. While swaddling likely does not reduce pain reactivity in preterm neonates (SMD -0.60, 95% CI -1.23 to 0.04, no effect; I2 = 91%, considerable heterogeneity), it has been shown to possibly improve immediate pain regulation (SMD -1.21, 95% CI -2.05 to -0.38, large effect; I2 = 89%, considerable heterogeneity), based on very low-certainty evidence. In full-term born neonates, non-nutritive sucking may reduce pain reactivity (SMD -1.13, 95% CI -1.57 to -0.68, large effect; I2 = 82%, considerable heterogeneity) and improve immediate pain regulation (SMD -1.49, 95% CI -2.20 to -0.78, large effect; I2 = 92%, considerable heterogeneity), based on very low-certainty evidence.  In full-term born older infants, structured parent involvement was the intervention most studied. Results showed that this intervention has little to no effect in reducing pain reactivity (SMD -0.18, 95% CI -0.40 to 0.03, no effect; I2 = 46%, moderate heterogeneity) or improving immediate pain regulation (SMD -0.09, 95% CI -0.40 to 0.21, no effect; I2 = 74%, substantial heterogeneity), based on low- to moderate-certainty evidence. Of these five interventions most studied, only two studies observed adverse events, specifically vomiting (one preterm neonate) and desaturation (one full-term neonate hospitalised in the NICU) following the non-nutritive sucking intervention. The presence of considerable heterogeneity limited our confidence in the findings for certain analyses, as did the preponderance of evidence of very low to low certainty based on GRADE judgements.

AUTHORS' CONCLUSIONS

Overall, non-nutritive sucking, facilitated tucking, and swaddling may reduce pain behaviours in preterm born neonates. Non-nutritive sucking may also reduce pain behaviours in full-term neonates. No interventions based on a substantial body of evidence showed promise in reducing pain behaviours in older infants. Most analyses were based on very low- or low-certainty grades of evidence and none were based on high-certainty evidence. Therefore, the lack of confidence in the evidence would require further research before we could draw a definitive conclusion.

Early Skin-to-Skin Contact in Preterm Infants: Is It Safe? An Italian Experience

Background: Skin-to-skin contact (SSC) is one of the four components of kangaroo care (KC) and is also a valued alternative to incubators in low-income countries. SSC has also become a standard of care in high-income countries because of its short- and long-term benefits and its positive effect on infant growth and neurodevelopmental outcome. However, barriers in the implementation of SSC, especially with preterm infants, are common in NICUs because parents and health care professionals can perceive it as potentially risky for the clinical stability of preterm infants. Previous studies have assessed safety before and during SSC by monitoring vital parameters during short-time intervals. Aims: To demonstrate the safety of early SSC in preterm infants during at least 90 min intervals. Design: Prospective observational monocentric study. Methods: Preterm infants born between June 2018 and June 2020 with a gestational age of ≤33 weeks and a birth weight of <2000 g were monitored while performing an SSC session during the first three weeks of life. Infants with necrotizing enterocolitis, sepsis, and congenital malformations on mechanical ventilation or with more than five apneas in the hour before SSC were excluded. Continuous oxygen saturation (SaO2), heart rate (HR), and respiratory rate (RR) were registered during an SSC session and in the hour before. The minimum duration of an SSC session was 90 min. Information regarding postmenstrual age (PMA), body weight, respiratory support, presence of a central venous catheter and the onset of sepsis within 72 h after a session was collected. Two physicians, blinded to infant conditions and the period of analysis (before or during SSC), evaluated desaturation episodes (SaO2 < 85%, >15 s), bradycardia (HR < 100, >15 s) and apneas (pause in breathing > 20 s associated with desaturation and/or bradycardia). A Wilcoxon rank sum test was used for the statistical analysis. Results: In total, 83 episodes of SSC were analyzed for a total of 38 infants. The mean gestational age at birth was 29 weeks (range 23–33 weeks). Median PMA, days of life, and body weight at SSC were 31 weeks (range 25–34 weeks), 10 days (range 1–20 days), and 1131 g (range 631–2206 g), respectively. We found that 77% of infants were on respiratory support and 47% of them had a central venous catheter (umbilical or peripherally inserted central catheter) during SSC. The total duration of desaturation, bradycardia, and the number of apneas were not statistically different during the SSC session and the hour before. No catheter dislocation or ruptures were reported. Conclusions: These findings highlighted the safety of early SSC in preterm infants and the possibility of performing it in an intensive care setting in the first weeks of life. In addition, these findings should reassure health care professionals offering this practice as a standard of care. SSC plays a key role in the care of preterm infants due to its short- and long-term positive benefits, and it deserves to be increasingly offered to infants and their parents.

A Randomized Comparative Effectiveness Study of Reflexology, Sucrose, and Other Treatments for Needle Procedures in Newborns

BACKGROUND

Approximately 10 to 14 painful procedures per day are performed in infants during the hospital stay. We aimed to determine the effect of reflexology applied to the sole during painful procedures on pain perception in newborns compared with other nonpharmacologic methods.

METHODS

Our study was planned as a randomized controlled trial in term infants being followed up in the neonatal intensive care unit and maternity ward. To reduce pain during collection of venous blood or heel lance reflexology on the soles of the foot, 24% sucrose solution, kangaroo care, and classical music listening were applied to the infants. The Neonatal Infant Pain Scale (NIPS) was used to assess newborns during acute pain.

RESULTS

A total of 300 patients were enrolled in the study. Higher pain scores and crying times were observed during heel blood collection. All analgesic methods significantly reduced NIPS scores during heel blood collection. Sucrose was the most effective method, followed by reflexology. The best method that significantly shortened the crying time was again sucrose solution followed by reflexology, kangaroo care, and classical music, during heel blood collection. However, none of the nonpharmacologic methods was effective during venous blood collection.

CONCLUSIONS

Although sucrose was the most effective method, reflexology has significant positive effects, especially on average heartbeat, reducing pain, and shortening crying times during heel blood sampling. Reflexology might be considered among the nonpharmacologic methods to be applied before routine interventions, but still, there is a need for further studies to investigate the efficiency.

Kangaroo Care for Relieving Neonatal Pain Caused by Invasive Procedures: A Systematic Review and Meta-Analysis

Objective. Neonates develop significant pain responses during invasive procedures, and nonpharmacological interventions are better means of pain relief. An increasing number of studies have confirmed the effectiveness of kangaroo care (KC) in relieving neonatal pain caused by invasive procedures, but conclusions are inconsistent. In this study, a literature search and meta-analysis were performed to evaluate the effect of kangaroo care on relieving neonatal pain. Methods. The works of literature related to the application of KC in neonatal invasive procedures in the databases of Pubmed, Embase, Springer Link, Ovid, CNKI, and CBM were searched, and the RCT literature from database establishment to July 2022, was selected to evaluate the risk of bias, combined with statistical pain relief outcome indicators. Results. 12 pieces of literature were finally included in this study, with a total of 1172 newborns, including 585 newborns (49.9%) using KC and 587 newborns (50.1%) using the control group method. Meta-analysis showed that an infant’s heart rate during invasive procedures under KC intervention was significantly lower than that of other interventions (MD = −6.77, 95% CI (−13.03, −0.50), Z = −2.12, $P=0.03$ ), but compared to other nonpharmacological interventions, there was no clear advantage in the overall evaluation of pain reduction in infants (MD = −0.36, 95% CI (−0.80, 0.08), Z = −1.60, $P=0.11$ ). Conclusion. The heart rate of KC intervention during invasive procedures in infants is significantly lower than that of other interventions, and it can significantly relieve pain in infants, but the effect is not more than that of oral sucrose (or glucose) or standard care. KC combined with oral sucrose may achieve a better pain relief effect in infants, but more studies are still needed to verify it.

Impact of Physical Contact on Preterm Infants' Vital Sign Response to Live Music Therapy

Evidence that music therapy stabilises vital parameters in preterm infants is growing, but the optimal setting for therapy is still under investigation. Our study aimed to quantify the effect of physical contact during live music therapy in preterm infants born < 32 weeks’ gestational age (GA) on post-therapy vital sign values. Live music therapy was delivered twice-weekly until discharge from hospital to 40 stable infants < 32 weeks’ GA. Baseline and post-therapy heart rate, respiratory rate, oxygen saturation and physical contact during each session were recorded. 159 sessions were performed with, and 444 sessions without, physical contact. Descriptive and multivariable regression analyses based on directed acyclic graphs were performed. The mean GA was 28.6 ± 2.6 weeks, and 26 (65%) infants were male. Mean absolute values for heart and respiratory rates lowered during music therapy regardless of physical contact. The mean post-therapy SaO2 was higher compared to baseline values regardless of physical contact (mean differences −8.6 beats/min; −13.3 breaths/min and +2.0%). There were no clinically relevant changes in vital sign responses between therapy sessions, with or without physical contact, or adjusted post-therapy values for any of the studied vital signs. Physical contact caused better baseline and post-therapy vital sign values but did not enhance the vital sign response to music therapy. Thus, the effect of music therapy on preterm infants’ vital signs is independent of physical contact and parents’ presence during music therapy in the neonatal intensive care unit.

Osteopathic Manipulative Treatment Regulates Autonomic Markers in Preterm Infants: A Randomized Clinical Trial

Osteopathic manipulative treatment (OMT) has been found to be effective in the context of premature infants. Nonetheless, no studies have investigated the immediate effects of OMT on heart rate variability (HRV). As altered HRV reflects poor or worsening newborn’s clinical conditions and neurodevelopment, should OMT improve HRV fluctuations, it could become a relevant intervention for improving the care of preterm newborns. Therefore, this study aimed to evaluate whether OMT could affect HRV. The study was carried out at the Buzzi Hospital in Milan. From the neonatal intensive care unit, ninety-six preterm infants (41 males) were enrolled and were randomly assigned to one of two treatment groups: OMT or Static Touch. The infants were born at 33.5 weeks (±4.3) and had a mean birth weight of 2067 g (±929). The study had as primary outcome the change in the beat-to-beat variance in heart rate measured through root mean square of consecutive RR interval differences (RMSSD); other metrics were used as secondary and exploratory analyses. Despite the lack of statistically significant results regarding the primary outcomeand some study limitations, compared to static touch, OMT seemed to favor a parasympathetic modulation and improved HRV, which could reflect improvement in newborn’s clinical conditions and development.

Vital signs as physiomarkers of neonatal sepsis

Neonatal sepsis accounts for significant morbidity and mortality, particularly among premature infants in the Neonatal Intensive Care Unit. Abnormal vital sign patterns serve as physiomarkers of sepsis and provide early warning of illness before overt clinical decompensation. The systemic inflammatory response to pathogens signals the autonomic nervous system, leading to changes in temperature, respiratory rate, heart rate, and blood pressure. In infants with comorbidities of prematurity, vital sign abnormalities often occur in the absence of infection, which confounds sepsis diagnosis. This review will cover the mechanisms of vital sign changes in neonatal sepsis, including the cholinergic anti-inflammatory pathway mediated by the vagus nerve, which is critical to the host response to infectious and inflammatory insults. We will also review the clinical implications of vital sign changes in neonatal sepsis, including their use in early warning scores and systems to direct clinicians to the bedside of infants with physiologic changes that might be due to sepsis. IMPACT: This manuscript summarizes and reviews the relevant literature on the physiological manifestations of neonatal sepsis and how we monitor and analyze these through vital signs and advanced analytics.

Systematic Review of the Effectiveness of Involving Parents During Painful Interventions for Their Preterm Infants

OBJECTIVE

To systematically review the literature related to the effectiveness of parents' active involvement during painful interventions for their preterm infants.

DATA SOURCES

We performed a systematic search of PubMed, EMBASE/Ovid, CINAHL, Livivio, and PsycInfo using the keywords "preterm infants," "pain," and "parents."

STUDY SELECTION

Articles were eligible for inclusion if they were published between 2000 and 2021 and reported randomized controlled trials (RCTs) in which preterm infants underwent painful interventions, and parents were present and actively involved in pain-reducing measures.

DATA EXTRACTION

We used the Consolidated Standards of Reporting Trials (CONSORT) checklist for RCTs for data extraction. We assessed methodologic quality using critical appraisal for RCTs according to the Joanna Briggs Institute.

DATA SYNTHESIS

In total, 22 articles met the inclusion criteria. These articles reported 19 studies focused on kangaroo/skin-to-skin care, one focused on breastfeeding, and two focused on facilitated tucking. The methods used to evaluate pain in the infant varied substantially. Overall, kangaroo/skin-to-skin care and facilitated tucking resulted in clinically and statistically significant decreases in pain. For breastfeeding, effectiveness was linked to a more mature sucking pattern of the preterm infant.

CONCLUSION

The current evidence suggests that involving parents in pain-reducing measures during painful interventions for their preterm infants is beneficial. However, more research is needed for the different methods of involving parents in pain-reducing measures.

Neonatal heart rate variability: a contemporary scoping review of analysis methods and clinical applications

BACKGROUND

Neonatal heart rate variability (HRV) is widely used as a research tool. However, HRV calculation methods are highly variable making it difficult for comparisons between studies.

OBJECTIVES

To describe the different types of investigations where neonatal HRV was used, study characteristics, and types of analyses performed.

ELIGIBILITY CRITERIA

Human neonates ≤1 month of corrected age.

SOURCES OF EVIDENCE

A protocol and search strategy of the literature was developed in collaboration with the McGill University Health Center's librarians and articles were obtained from searches in the Biosis, Cochrane, Embase, Medline and Web of Science databases published between 1 January 2000 and 1 July 2020.

CHARTING METHODS

A single reviewer screened for eligibility and data were extracted from the included articles. Information collected included the study characteristics and population, type of HRV analysis used (time domain, frequency domain, non-linear, heart rate characteristics (HRC) parameters) and clinical applications (physiological and pathological conditions, responses to various stimuli and outcome prediction).

RESULTS

Of the 286 articles included, 171 (60%) were small single centre studies (sample size <50) performed on term infants (n=136). There were 138 different types of investigations reported: physiological investigations (n=162), responses to various stimuli (n=136), pathological conditions (n=109) and outcome predictor (n=30). Frequency domain analyses were used in 210 articles (73%), followed by time domain (n=139), non-linear methods (n=74) or HRC analyses (n=25). Additionally, over 60 different measures of HRV were reported; in the frequency domain analyses alone there were 29 different ranges used for the low frequency band and 46 for the high frequency band.

CONCLUSIONS

Neonatal HRV has been used in diverse types of investigations with significant lack of consistency in analysis methods applied. Specific guidelines for HRV analyses in neonates are needed to allow for comparisons between studies.

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.

Soothing Effect of an Edible Teether: A Pilot Study in Children during Primary Dentition Age

Background

Irritability and discomfort are common symptoms during teething periods in infants and toddlers. Non-pharmacological remedies to relieve teething symptoms include teethers and food for chewing. However, the efficacy of such remedies for their soothing effect has been poorly investigated.

Materials and methods

In this home-based pilot study, the soothing effect of a novel edible teether with a slowly dissolvable texture was investigated in 12 children aged 5 to 19 months old during primary dentition age. After parents observed their child getting irritable, the child received the edible teether for an exposure duration of 15 to 20 minutes. Parental ratings of children's mood states (crankiness, stress, happiness, and calmness) were collected using visual analog scales, and child cardiac measurements (heart rate and heart rate variability) were assessed using a wearable device. The soothing effect was quantified via mood ratings and physiological calming responses as a before-after comparison using Wilcoxon signed-rank tests.

Results

Parents perceived their child as significantly calmer and happier, less stressed, and marginally less cranky after edible teether exposure than before. The child cardiac variables showed no significant changes; however, exposure to the teether induced a marginal increase in HR within normal ranges, potentially indicating a stimulation effect.

Conclusion

The pilot study provides the first insight on the soothing effect of a novel edible teether on parent-reported mood states in young children during primary dentition age. Further research is needed to understand the relative contribution of the different components of an edible teether to the observed effects, such as texture and exposure duration, and to demonstrate its efficacy against a control product.

Trial registration

Swiss registry of clinical trial: CER-VD 2019-02155.

How to cite this article

Lerond C, Hudry J, Zahar S, et al. Soothing Effect of an Edible Teether: A Pilot Study in Children during Primary Dentition Age. Int J Clin Pediatr Dent 2021;14(4):525–530.

Effects of Live Music Therapy on Autonomic Stability in Preterm Infants: A Cluster-Randomized Controlled Trial

Unbuffered stress levels may negatively influence preterm-infants’ autonomic nervous system (ANS) maturation, thus affecting neurobehavior and psycho-emotional development. Music therapy (MT) is an evidence-based treatment modality in neonatal care. When coupled with skin-to-skin care (SSC), it may reduce stress responses in both preterm infants and their parents and enhance family-centered care. Accordingly, we aimed to compare the effects of combined MT and SSC and SSC alone on ANS stabilization in preterm infants. In a single-center, cluster-randomized trial design, ten two-month time-clusters were randomized to either combined MT and SSC or SSC alone. Families of preterm infants were offered two sessions of the allocated condition in the NICU, and a three-month follow up session at home. The primary outcome variable was stabilization of the ANS, defined by change in the high frequency (HF) power of heart rate variability (HRV) during the second session. Secondary outcomes included other HRV measures, parent–infant attachment, and parental anxiety at each session. Sixty-eight families were included. MT combined with SSC improved infants’ ANS stability, as indicated by a greater increase in HF power during MT compared to SSC alone (mean difference 5.19 m²/Hz, SE = 1.27, p < 0.001) (95% confidence interval 0.87 to 2.05). Most secondary outcomes were not significantly different between the study groups. MT contributes to preterm-infants’ autonomic stability, thus laying an important foundation for neuro-behavioral and psycho-emotional development. Studies evaluating longer-term effects of MT on preterm infants’ development are warranted.

Available Instruments to Assess Pain in Infants

Pain assessment in newborns and infants is challenging for clinicians. Although behavioral and behavioral-physiological scales are validated pain assessment instruments, their use in this age group has significant limitations. In this review, we summarize the methods currently available for assessing pain in neonates and infants. It is possible that these pain detection methods are also useful for assessing the quality of anesthesia and analgosedation in these populations. Further research should be aimed at confirming the usefulness of these tools in infants and identifying additional pain assessment options for clinical practice.

The effect of early procedural pain in preterm infants on the maturation of electroencephalogram and heart rate variability

ABSTRACT

Preterm infants show a higher incidence of cognitive, social, and behavioral problems, even in the absence of major medical complications during their stay in the neonatal intensive care unit (NICU). Several authors suggest that early-life experience of stress and procedural pain could impact cerebral development and maturation resulting in an altered development of cognition, behavior, or motor patterns in later life. However, it remains very difficult to assess this impact of procedural pain on physiological development. This study describes the maturation of electroencephalogram (EEG) signals and heart rate variability in a prospective cohort of 92 preterm infants (<34 weeks gestational age) during their NICU stay. We took into account the number of noxious, ie, skin-breaking, procedures they were subjected in the first 5 days of life, which corresponded to a median age of 31 weeks and 4 days. Using physiological signal modelling, this study shows that a high exposure to early procedural pain, measured as skin-breaking procedures, increased the level of discontinuity in both EEG and heart rate variability in preterm infants. These findings have also been confirmed in a subset of the most vulnerable preterm infants with a gestational age lower than 29 weeks. We conclude that a high level of early pain exposure in the NICU increases the level of functional dysmaturity, which can ultimately impact preterm infants' future developmental outcome.

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.

The Effect of 3 Positions Given to Preterm Infants During Heelstick Procedure on Pain and Durations of Crying and Procedure

The purpose of this randomized controlled study was to determine the effect of 3 positions given to preterm infant during heelstick procedure on the pain and durations of crying and procedure. The sample of the study consisted of 90 preterm infants (30 in each group). The heelstick procedure was video recorded. Data from the pain scores, durations of crying, and procedure were collected watching the video recordings. It was determined that the pain mean score of the infants in the control group (supine on the crib) (5.50 ± 2.13) was statistically significantly higher than that of the infants in the positions of upright (3.00 ± 2.17) and supine on the lap (3.20 ± 2.46) (P < .01), and there was no difference between the positions of upright and supine on the lap (P > .05). Giving the positions of upright or supine on the lap during heelstick is effective in reducing pain, shortening the duration of crying, and calming down the infant. Heelstick in the position of upright on the lap shortened the procedure duration and allowed the infants to be subjected to less painful procedure. It is recommended for nurses to take the preterm infants on their laps during heel lancing and give them the upright position, in particular.

The burden of early life stress on the nociceptive system development and pain responses

For a long time, the capacity of the newborn infant to feel pain was denied. Today it is clear that the nociceptive system, even if still immature, is functional enough in the newborn infant to elicit pain responses. Unfortunately, pain is often present in the neonatal period, in particular in the case of premature infants which are subjected to a high number of painful procedures during care. These are accompanied by a variety of environmental stressors, which could impact the maturation of the nociceptive system. Therefore, the question of the long-term consequences of early life stress is a critical question. Early stressful experience, both painful and non-painful, can imprint the nociceptive system and induce long-term alteration in brain function and nociceptive behavior, often leading to an increase sensitivity and higher susceptibility to chronic pain. Different animal models have been developed to understand the mechanisms underlying the long-term effects of different early life stressful procedures, including pain and maternal separation. This review will focus on the clinical and preclinical data about early life stress and its consequence on the nociceptive system.

Recovering Together: Mothers' Experiences Providing Skin-to-Skin Care for Their Infants With NAS

BACKGROUND

Over the past 2 decades, the prevalence of neonatal abstinence syndrome (NAS) has increased almost 5-fold. Skin-to-skin care (SSC), a method of parent-infant holding, is a recommended nonpharmacologic intervention for managing NAS symptoms. SSC has the potential to reduce withdrawal symptoms while positively influencing parent-infant attachment. Yet, little is known about the SSC experiences of mothers of infants with NAS.

PURPOSE

The purpose of this study was to explore the SSC experiences of mothers of infants with NAS, including perceived barriers to SSC in the hospital and following discharge home.

METHODS

A qualitative descriptive design was used to obtain new knowledge regarding the experience of SSC of mothers of infants with NAS. Purposive sampling was used to recruit participants eligible for the study. We conducted semistructured individual interviews with postpartum mothers of infants with NAS. Data were analyzed using thematic analysis.

FINDINGS/RESULTS

Thirteen mothers participated in the study. Four themes emerged from the data analysis: "a little nerve racking"; "she needed me, and I needed her"; dealing with the "hard times"; and "a piece of my puzzle is missing." SSC was described as a conduit for healing and bonding; in addition, several barriers to SSC were reported.

IMPLICATIONS FOR PRACTICE AND RESEARCH

These findings highlight the inherent benefits of SSC for infants with NAS and demonstrate the unique challenges of these mother-infant dyads. Critical changes in hospital practices are needed to create an environment supportive of SSC for this patient population. In addition, research regarding implementation of interventions to increase SSC usage in this population is warranted.

Newborn infant parasympathetic evaluation for the assessment of analgosedation adequacy in infants treated by mechanical ventilation - a multicenter pilot study

INTRODUCTION

Adequate analgosedation is important in infants treated in pediatric/neonatal intensive care units (P/NICUs), because both too deep and insufficient analgosedation is disadvantageous. To assess the severity of pain, several behavioral and behavioral-physiological scales are used, but their usefulness is limited. It is therefore justified to search for additional methods to assess the adequacy of analgosedation in these patients. The aim of the present study is to evaluate the usefulness of Newborn Infant Parasympathetic Evaluation (NIPE) in the assessment of analgosedation quality in infants requiring mechanical ventilation, who are treated in P/NICUs.

MATERIAL AND METHODS

We performed simultaneously 180 COMFORT-B assessments and heart rate variability measurements using a NIPE monitor in 30 mechanically ventilated infants receiving analgosedation. A generalized linear mixed model with the logit link function was used in order to perform logistic regression analysis to assess the relationship between NIPEi/NIPEm and deep sedation.

RESULTS

The multivariable logistic regression model showed that NIPEi and NIPEm values were higher when analgosedation was deep as compared to when it was moderate or insufficient (OR (95% CI): NIPEm - 1.065 (1.007-1.126), p = 0.03; NIPEi - 1.068 (1.016-1.123), p = 0.01).

CONCLUSIONS

The NIPE indexes are significantly higher in patients whose assessment on the behavioral scale indicates deep analgosedation as compared to those in whom it indicates moderate or insufficient analgosedation. Allowing continuous monitoring, the NIPE device may be a valuable assisting tool in the assessment of analgosedation quality in mechanically ventilated newborns and infants.

Co-bedding of Preterm Newborn Pigs Reduces Necrotizing Enterocolitis Incidence Independent of Vital Functions and Cortisol Levels

Background: Preterm infants are born with immature organs, leading to morbidities such as necrotizing enterocolitis (NEC), a gut inflammatory disease associated with adverse feeding responses but also hemodynamic and respiratory instability. Skin-to-skin contact including "kangaroo care" may improve infant survival and health via improved vital functions (e.g., pulmonary, cardiovascular) and endocrine influences by adrenal glucocorticoids. Clinical effects of skin-to-skin contact for newborn siblings ("co-bedding") are not known. Using NEC-susceptible Preterm pigs as models, we hypothesized that co-bedding and exogenous glucocorticoids improve vital functions and NEC resistance. Methods: In experiment 1, cesarean-delivered, formula-fed Preterm pigs were reared in incubators with (co-bedding, COB, n = 30) or without (single-bedding, SIN, n = 29) a sibling until euthanasia and tissue collection on day four. In experiment 2, single-bedded Preterm pigs were treated postnatally with a tapering dose of hydrocortisone (HC, n = 19, 1-3 mg/kg/d) or saline (CON, n = 19). Results: Co-bedding reduced NEC incidence (38 vs. 65%, p < 0.05) and increased the density of colonic goblet cells (+20%, p < 0.05) but had no effect on pulmonary and cardiovascular functions (respiration, blood pressure, heart rate, blood gases) or cortisol levels. There were limited differences in intestinal villous architecture and digestive enzyme activities. In experiment 2, HC treatment increased NEC lesions in the small intestine without any effects on pulmonary or cardiovascular functions. Conclusion: Co-bedding may improve gut function and NEC resistance independently of cardiorespiratory function and cortisol levels, but pharmacological cortisol treatment predispose to NEC. Preterm pigs may be a useful tool to better understand the physiological effects of co-bedding, neonatal stressors and their possible interactions with morbidities in Preterm neonates.

Short-time effect of the kangaroo position on electromyographic activity of premature infants: a randomized clinical trial

OBJECTIVE

To verify the short-term influence of the kangaroo position (KP) on the electromyography activity of preterm newborns.

METHOD

A clinical study was conducted in a kangaroo unit sector (secondary and tertiary care) in the city of Recife, Brazil, with 44 preterm infants randomized to intervention (n=21) and control (n=23) groups. The KP was performed through a band that supports the newborn against the adult's thorax, in a prone and vertical position, and infants were dressed with few pieces of clothes, thus keeping skin-to-skin contact with the mother. Surface electromyography was used to investigate the muscle activity of the biceps brachii and hamstrings. The randomization of the groups was performed by the program R® (v. 3.3.1). The electromyography registrations were made at three different times: before the KP and after one and two hours of KP. In the control group, the registrations were performed at the times corresponding to those of the intervention group. The mean values of the electromyography activity among the times were analyzed by ANOVA for repeated measures and the Kruskal-Wallis test. The clinical trial was recorded in ClinicalTrials.gov (NCT02849665 - 07/28/2016).

RESULTS

In the intervention group (n=21), there was a variation of the electromyography activity values between the three recording moments for both the biceps brachii and hamstrings. In the control group (n=23), there was no statistical difference between the recording moments for both.

CONCLUSIONS

The KP increases the short-term electromyographic activity of the biceps brachii and hamstrings.

Development of locally relevant clinical guidelines for procedure-related neonatal analgesic practice in Kenya: a systematic review and meta-analysis

Background Increasing numbers of neonates are undergoing painful procedures in low-income and middle-income countries, with adequate analgesia seldom used. In collaboration with a multi-disciplinary team in Kenya, we aimed to establish the first evidence-based guidelines for the management of routine procedure-related neonatal pain that consider low-resource hospital settings.

METHODS

We did a systematic review by searching MEDLINE, Embase, CINAHL, and CENTRAL databases for studies published from Jan 1, 1953, to March 31, 2019. We included data from randomised controlled trials using heart rate, oxygen saturation (SpO2), premature infant pain profile (PIPP) score, neonatal infant pain scale (NIPS) score, neonatal facial coding system score, and douleur aiguë du nouveau-né scale score as pain outcome measures. We excluded studies in which neonates were undergoing circumcision or were intubated, studies from which data were unextractable, or when pain was scored by non-trained individuals. We did a narrative synthesis of all studies, and meta-analysis when data were available from multiple studies comparing the same analgesics and controls and using the same outcome measures. 17 Kenyan health-care professionals formed our clinical guideline development panel, and we used the Grading of Recommendations, Assessment, Development and Evaluation framework and the panel's knowledge of the local health-care context to guide the guideline development process. This study is registered with PROSPERO, CRD42019126620.

FINDINGS

Of 2782 studies assessed for eligibility, data from 149 (5%) were analysed, with 80 (3%) of these further contributing to our meta-analysis. We found a high level of certainty for the superiority of breastfeeding over placebo or no intervention (standardised mean differences [SMDs] were -1·40 [95% CI -1·96 to -0·84] in PIPP score and -2·20 [-2·91 to -1·48] in NIPS score), and the superiority of oral sugar solutions over placebo or no intervention (SMDs were -0·38 [-0·61 to -0·16] in heart rate and 0·23 [0·04 to 0·42] in SpO2). We found a moderate level of certainty for the superiority for expressed breastmilk over placebo or no intervention (SMDs were -0·46 [95% CI -0·87 to -0·05] in heart rate and 0·48 [0·20 to 0·75] in SpO2). Therefore, the panel recommended that breastfeeding should be given as first-line analgesic treatment, initiated at least 2 min pre-procedure. Given contextual factors, for neonates who are unable to breastfeed, 1-2 mL of expressed breastmilk should be given as first-line analgesic, or 1-2 mL of oral sugar (≥10% concentration) as second-line analgesic. The panel also recommended parental presence during procedures with adjunctive provision of skin-to-skin care, or non-nutritive sucking when possible.

INTERPRETATION

We have generated Kenya's first neonatal analgesic guidelines for routine procedures, which have been adopted by the Kenyan Ministry of Health, and have shown a framework for clinical guideline development that is applicable to other low-income and middle-income health-care settings.

FUNDING

Wellcome Trust Research Programme, and the Africa-Oxford Initiative.

The impact of parental contact upon cortical noxious-related activity in human neonates

BACKGROUND

Neonates display strong behavioural, physiological and cortical responses to tissue-damaging procedures. Parental contact can successfully regulate general behavioural and physiological reactivity of the infant, but it is not known whether it can influence noxious-related activity in the brain. Brain activity is highly dependent upon maternal presence in animal models, and therefore this could be an important contextual factor in human infant pain-related brain activity.

METHODS

Global topographic analysis was used to identify the presence and inter-group differences in noxious-related activity in three separate parental contexts. EEG was recorded during a clinically required heel lance in three age and sex-matched groups of neonates (a) while held by a parent in skin-to-skin (n = 9), (b) while held by a parent with clothing (n = 9) or (c) not held at all, but in individualized care (n = 9).

RESULTS

The lance elicited a sequence of 4-5 event-related potentials (ERPs), including the noxious ERP (nERP), which was smallest for infants held skin-to-skin and largest for infants held with clothing (p=0.016). The nERP was then followed by additional and divergent long-latency ERPs (> 750 ms post-lance), not previously described, in each of the groups, suggesting the engagement of different higher level cortical processes depending on parental contact.

CONCLUSIONS

These results show the importance of considering contextual factors in determining infant brain activity and reveal the powerful influence of parental contact upon noxious-related activity across the developing human brain.

SIGNIFICANCE

This observational study found that the way in which the neonatal brain processes a noxious stimulus is altered by the type of contact the infant has with their mother. Specifically, being held in skin-to-skin reduces the magnitude of noxious-related cortical activity. This work has also shown that different neural mechanisms are engaged depending on the mother/infant context, suggesting maternal contact can change how a baby's brain processes a noxious stimulus.

Impact of Skin-to-Skin Parent-Infant Care on Preterm Circulatory Physiology

OBJECTIVES

To ascertain the impact of skin-to-skin care between parents and infants on cardiac function and cerebral blood flow in preterm infants.

STUDY DESIGN

We undertook a prospective study of 40 self-ventilating preterm infants at a quaternary center and assessed cardiac performance and cerebral blood flow. Assessments were carried out two hours before skin-to-skin care and then 60 minutes after skin-to-skin care (with the infant still on parent and turned supine).

RESULTS

Infants were 30.5 ± 0.6 weeks' gestational age and 1378 ± 133 g birthweight. Axillary temperature noted a nonsignificant increase during skin-to-skin care from 36.7 ± 0.07°C to 36.9 ± 0.07°C (P = .07). Cardiac contractility (right ventricular fractional area change [26.5% ± 0.3% vs 27.8% ± 0.4; P < .001] and tricuspid annular plane systolic excursion [0.73 ± 0.03 cm vs 0.77 ± 0.03 cm; P = .02]) increased significantly, coincident with decreased measures of pulmonary vascular resistance. An increase in systemic cardiac output was associated with increased cerebral blood flow and reduced middle cerebral artery resistive index (0.81 ± 0.02 vs 0.74 ± 0.02; P = .0001).

CONCLUSIONS

We documented a significant circulatory beneficial adaptation to a common neonatal practice. These findings align with previously documented physiologic benefits in cardiorespiratory stability and cardiac rhythm in preterm infants, and may be mediated through modulation of the autonomic nervous system.

Operationalising kangaroo Mother care before stabilisation amongst low birth Weight Neonates in Africa (OMWaNA): protocol for a randomised controlled trial to examine mortality impact in Uganda

Background

There are 2.5 million neonatal deaths each year; the majority occur within 48 h of birth, before stabilisation. Evidence from 11 trials shows that kangaroo mother care (KMC) significantly reduces mortality in stabilised neonates; however, data on its effect among neonates before stabilisation are lacking. The OMWaNA trial aims to determine the effect of initiating KMC before stabilisation on mortality within seven days relative to standard care. Secondary objectives include exploring pathways for the intervention’s effects and assessing incremental costs and cost-effectiveness between arms.

Methods

We will conduct a four-centre, open-label, individually randomised, superiority trial in Uganda with two parallel groups: an intervention arm allocated to receive KMC and a control arm receiving standard care. We will enrol 2188 neonates (1094 per arm) for whom the indication for KMC is ‘uncertain’, defined as receiving ≥ 1 therapy (e.g. oxygen). Admitted singleton, twin and triplet neonates (triplet if demise before admission of ≥ 1 baby) weighing ≥ 700–≤ 2000 g and aged ≥ 1–< 48 h are eligible. Treatment allocation is random in a 1:1 ratio between groups, stratified by weight and recruitment site. The primary outcome is mortality within seven days. Secondary outcomes include mortality within 28 days, hypothermia prevalence at 24 h, time from randomisation to stabilisation or death, admission duration, time from randomisation to exclusive breastmilk feeding, readmission frequency, daily weight gain, infant–caregiver attachment and women’s wellbeing at 28 days. Primary analyses will be by intention-to-treat. Quantitative and qualitative data will be integrated in a process evaluation. Cost data will be collected and used in economic modelling.

Discussion

The OMWaNA trial aims to assess the effectiveness of KMC in reducing mortality among neonates before stabilisation, a vulnerable population for whom its benefits are uncertain. The trial will improve understanding of pathways underlying the intervention’s effects and will be among the first to rigorously compare the incremental cost and cost-effectiveness of KMC relative to standard care. The findings are expected to have broad applicability to hospitals in sub-Saharan Africa and southern Asia, where three-quarters of global newborn deaths occur, as well as important policy and programme implications.

Trial registration

ClinicalTrials.gov, NCT02811432. Registered on 23 June 2016.

An intervention to decrease time to parents' first hold of infants in the Neonatal Intensive Care Unit requiring respiratory support

BACKGROUND

There are many barriers to parental skin-to-skin contact for critically ill neonates. Our aims were to decrease median time to first parental hold of neonates requiring respiratory support from 6.4 to 3 days, and to increase the percentage of neonates held within the first 24 h after birth from 6 to 75%.

METHODS

Lean Six Sigma methodology was used to identify barriers to holding and opportunities for improvement.

INTERVENTION

A multifactorial improvement bundle was implemented to reduce the time to first parental hold of critically ill neonates.

RESULTS

Median time to first parental hold was reduced from 6.4 to 1.2 days (p < 0.01). Infants held within the first 24 h after birth increased from 6 to 35%. There was no increase in adverse events associated with parental holding.

CONCLUSIONS

Implementation of an improvement bundle resulted in a significant reduction in time to first parental hold of infants requiring respiratory support.

Safety and feasibility of skin-to-skin care for surgical infants: A quality improvement project

BACKGROUND

Skin-to-skin care (SSC) for infants improves physiologic stability, pain perception, brain development, parental bonding, and overall survival. Using quality improvement (QI) methodology, this project aimed to increase SSC for surgical infants in the neonatal intensive care unit (NICU).

METHODS

A multidisciplinary working group composed of key NICU stakeholders instituted a needs assessment querying perceptions and concerns about SSC. Based on survey results, multiple system level interventions were implemented. Data for surgical infants receiving SSC during hospitalization were tracked over time using the electronic health record.

RESULTS

Overall, 315 infants requiring a surgical consult were admitted to the NICU in the first 12 months of the project. After six months, SSC rates in this group increased from 51% to 60.5% (p < 0.01) and were sustained for 12 months. After one year, nursing staff reporting that they were somewhat to very comfortable providing SSC for surgical infants increased from 44% to 75% (p = 0.001) and the percent of nurses providing SSC for a surgical infant increased from 12% to 37% (p = 0.001). Inadvertent extubation did not significantly increase after implementation of the QI project.

CONCLUSIONS

Using QI methodology and multidisciplinary engagement, SSC was integrated safely into the routine care of surgical infants in the NICU.

LEVEL OF EVIDENCE

Level V.

WITHDRAWN: Short-time effect of the kangaroo position on electromyographic activity of premature infants: a randomized clinical trial

The Publisher regrets that this article is an accidental duplication of an article that has already been published, https://doi.org/. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Managing Procedural Pain in the Neonate Using an Opioid-sparing Approach

PURPOSE

Pain in the neonate is often challenging to assess but important to control. Physicians often must balance the need for optimal pain control with the need to minimize oversedation and prolonged opioid use. Both inadequate pain control and overuse of opioids can have long-term consequences, including poor developmental outcomes. The aim of this review is to introduce a comprehensive approach to pain management for physicians, nurses, and surgeons caring for critically ill neonates, focusing on nonopioid alternatives to manage procedural pain.

FINDINGS

After review, categories of opioid-sparing interventions identified included (1) nonopioid pharmacologic agents, (2) local and regional anesthesia, and (3) nonpharmacologic alternatives. Nonopioid pharmacologic agents identified for neonatal use included acetaminophen, NSAIDs, dexmedetomidine, and gabapentin. Local and regional anesthesia included neuraxial blockade (spinals and epidurals), subcutaneous injections, and topical anesthesia. Nonpharmacologic agents uniquely available in the neonatal setting included skin-to-skin care, facilitated tucking, sucrose, breastfeeding, and nonnutritive sucking.

IMPLICATIONS

The use of various pharmacologic and interventional treatments for neonatal pain management allows for the incorporation of opioid-sparing techniques in neonates who are already at risk for poor neurodevelopmental outcomes. A multifactorial approach to pain control is paramount to optimize periprocedural comfort and to minimize the negative sequelae of uncontrolled pain in the neonate.

An integrative review: maternal engagement in the neonatal intensive care unit and health outcomes for U.S.-born preterm infants and their parents

Hospitals and perinatal organizations recognize the importance of family engagement in the neonatal intensive care unit (NICU). The Agency for Healthcare Research and Quality (AHRQ) defines family engagement as "A set of behaviors by patients, family members, and health professionals and a set of organizational policies and procedures that foster both the inclusion of patients and family members as active members of the health care team and collaborative partnerships with providers and provider organizations." In-unit barriers and facilitators to enhance family engagement are well studied; however, less is known specifically about maternal engagement's influence in the NICU on the health of infants and mothers, particularly within U.S. social and healthcare contexts. In this integrative review, we examine the relationship between maternal engagement in the NICU and preterm infant and maternal health outcomes within the U.S. Results from the 33 articles that met inclusion criteria indicate that maternal engagement in the NICU is associated with infant outcomes, maternal health-behavior outcomes, maternal mental health outcomes, maternal-child bonding outcomes, and breastfeeding outcomes. Skin-to-skin holding is the most studied maternal engagement activity in the U.S. preterm NICU population. Further research is needed to understand what types of engagement are most salient, how they should be measured, and which immediate outcomes are the best predictors of long-term health and well-being.

Increased Frequency of Skin-to-Skin Contact Is Associated with Enhanced Vagal Tone and Improved Health Outcomes in Preterm Neonates

OBJECTIVE

An estimation of the individual's ability to cope with environmental adversity, that is, stress resiliency, can be extrapolated by measuring cardiac vagal tone, that is, high-frequency heart rate variability (HF-HRV); indeed, higher HF-HRV is associated with health and developmental advantages for preterm neonates. Previous studies show skin-to-skin contact (SSC) improves stress resiliency; however, linkages between SSC and HF-HRV on outcomes have not been assessed. We aimed to test the hypothesis that increased SSC frequency would enhance HF-HRV, reduce neonatal morbidity, and improve developmental outcomes.

STUDY DESIGN

Weekly electrocardiograms and clinical data were obtained from 101 preterm neonates. SSC frequency was determined from the electronic medical record.

RESULTS

At postnatal week 1, frequency of SSC and HF-HRV were positively correlated (p =.02); further, multiple stepwise regressions showed higher HF-HRV and SSC predicted reduced days on ventilation and oxygen, and shorter hospital stay (p < 0.001). Higher HF-HRV predicted lower postmenstrual age (PMA) at discharge (p < 0.01).

CONCLUSION

Higher SSC frequency was associated with increased HF-HRV during the first postnatal week. SSC and HF-HRV uniquely predicted diminished neonatal morbidity throughout hospitalization. Additionally, HF-HRV uniquely predicted earlier PMA at discharge. Augmenting SSC early in life enhances stress resiliency and improves health outcomes.

Neonatal Pain: Perceptions and Current Practice

Neonates may experience more than 300 painful procedures throughout their hospitalizations. Prior to 1980, there was a longstanding misconception that neonates do not experience pain. Current studies demonstrate that not only do neonates experience pain but also, due to their immature nervous systems, they are hypersensitive to painful stimuli. Poorly treated pain may lead to negative long-term consequences. Proper assessment of neonate pain is vital. The use of nonpharmacologic treatments may be beneficial in alleviating neonate pain. Pharmacologic treatments in the neonate have been well established. Pharmacologic and nonpharmacologic interventions can be used in conjunction to increase the efficacy of analgesia.

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.

Physiology of Stress and Use of Skin-to-Skin Care as a Stress-Reducing Intervention in the NICU

Advances in neonatal care have allowed for the increasing survival of critically ill infants. These infants experience significant stress related to painful procedures and physical separation from their parents. The purpose of this article is to describe the physiologic stress mechanisms that contribute to mortality and morbidity in infants in the NICU and the physiologic mechanisms by which skin-to-skin care (SSC) acts on the stress response system. Findings from current literature supporting the use of SSC and barriers and facilitators to implementation are reviewed. SSC is a safe and effective intervention to reduce stress for infants and their parents. Nurses play a key role in facilitating SSC to optimize outcomes of care in the NICU.

The biological embedding of neonatal stress exposure: A conceptual model describing the mechanisms of stress-induced neurodevelopmental impairment in preterm infants

The biological embedding of early life stress exposure may result in life-long neurodevelopmental impairment in preterm infants. Infants hospitalized in the neonatal intensive care unit are exposed to significant experiential, environmental, and physiologic stressors over the course of their extended hospitalization. Stress exposure during the sensitive period of brain development may alter biological processes, including functioning of the immune system, the autonomic nervous system, and the hypothalamic-pituitary-adrenal axis as well as gene expression. These alterations may subsequently affect brain structure and function. Changes to these processes may mediate the relationship between neonatal stress exposure and neurodevelopment in preterm infants and represent potential therapeutic targets to improve long-term outcomes. The purpose of this paper is to introduce a conceptual model, based on published research, that describes the mechanisms mediating stress exposure and neurodevelopment impairment in preterm infants and to provide the theoretical foundation on which to base future descriptive research, intervention studies, and clinical care.

Regular and prolonged skin-to-skin contact improves short-term outcomes for very preterm infants: A dose-dependent intervention

INTRODUCTION

Skin-to-skin contact (SSC) is a cornerstone of neurodevelopment and family-oriented care for preterm infants. The purpose of the present study was to investigate the effectiveness of skin-to-skin contact in preterm babies depending on regularity, duration, and the period of the first contact.

MATERIALS AND METHODS

This retrospective study involved 26 premature infants with gestational age 24/0-28/6 weeks who were treated in the neonatal intensive care unit and neonatal department. All infants had SSC with their parents.

RESULTS

According to the first SSC, newborns were divided into two groups: group 1 (SSC began in the 1st week of life) and group 2 (SSC began after the 1st week of life). Group A (SSC was performed regularly, i.e., everyday) and group B (SSC was irregular, i.r., once every 2 or 3 days) were based on the regularity of SSC. Depending on the duration of SSC, group І (SSC was more than 3h per day) and group II (SSC was less than 3h per day) were formed. Early SSC correlated with lower incidence of secondary infections (OR=6.75; 95% CI 1.06-42.84; P=0.051), bronchopulmonary dysplasia (OR=10.67; 95% CI 1.70-66.72; P<0.015), and cholestasis (P=0.022). Regular SSC correlated with lower incidence of secondary infections (OR=15.0; 95% CI 1.50-149.70; P=0.014). Duration of SSC was correlated with lower rates of secondary infections (OR=7.00; 95% CI 1.20-40.83; P=0.043) and better rates of breastfeeding (OR=7.00; 95% CI 1.20-40.83; P=0.043).

CONCLUSION

Early, regular, and prolonged SSC has a positive impact on premature infants' health. In particular, early SSC is associated with a reduced risk of BPD development, cholestasis, and nosocomial infection. Prolonged daily skin-to-skin contact is associated with a lower incidence of nosocomial infection and promotes breastfeeding.

Social touch during development: Long-term effects on brain and behavior

In this paper, our goal is to explore what is known about the role of social touch during development. We first address the neural substrates of social touch and the role of tactile experience in neural development. We discuss natural variation in early exposure to social touch, followed by a discussion on experimental manipulations of social touch during development and "natural experiments", such as early institutionalization. We then consider the role of other developmental and experiential variables that predict social touch in adults. Throughout, we propose and consider new theoretical models of the role of social touch during development on later behavior and neurobiology.

Evaluation of prolonged pain in preterm infants with pneumothorax using heart rate variability analysis and EDIN (Échelle Douleur Inconfort Nouveau-Né, neonatal pain and discomfort scale) scores

Purpose

The EDIN scale (Échelle Douleur Inconfort Nouveau-Né, neonatal pain and discomfort scale) and heart rate variability has been used for the evaluation of prolonged pain. The aim of our study was to assess the value of the newborn infant parasympathetic evaluation (NIPE) index and EDIN scale for the evaluation of prolonged pain in preterm infants with chest tube placement due to pneumothorax.

Methods

This prospective observational study assessed prolonged pain in preterm infants with a gestational age between 33 and 35 weeks undergoing installation of chest tubes. Prolonged pain was assessed using the EDIN scale and NIPE index.

Results

There was a significant correlation between the EDIN scale and NIPE index (r=-0.590, P=0.003). Prolonged pain is significantly more severe in the first 6 hours following chest tube installation (NIPE index: 60 [50–86] vs. 68 [45–89], P<0.002; EDIN score: 8 [7–11] vs. 6 [4–8], P<0.001).

Conclusion

Prolonged pain can be accurately assessed with the EDIN scale and NIPE index. However, evaluation with the EDIN scale is time-consuming. The NIPE index can provide instantaneous assessment of prolonged and continuous pain.

Safety of Reiki Therapy for Newborns at Risk for Neonatal Abstinence Syndrome

The incidence of opioid abuse and subsequent drug withdrawal is exponentially on the rise in the United States for many populations including newborns who are born to drug-addicted mothers. These newborns often exhibit symptoms of neonatal abstinence syndrome (NAS) within 24 to 72 hours of birth. Treatment of NAS includes monitoring of withdrawal symptoms, managing physiological parameters, and the use of supportive and pharmacologic treatments. Although a few randomized controlled trials exist, studies on supportive intervention are generally limited by small sample sizes, case study reports, expert opinions, and descriptive design. Few studies address the safety of Reiki for newborns at risk for NAS using neonatal parameters. This pilot study addresses feasibility and demonstrates that Reiki is safe when administered to this high-risk population. Considerations for future studies are discussed.

Increase in Oxytocin From Skin-to-Skin Contact Enhances Development of Parent–Infant Relationship

Objective:

To examine changes that occur in infant and parent salivary oxytocin (OT) and salivary cortisol (SC) levels during skin-to-skin contact (SSC) and whether SSC alleviates parental stress and anxiety while also supporting mother–father–infant relationships.

Methods:

This randomized crossover study was conducted in the neonatal intensive care unit (NICU) with a sample of 28 stable preterm infants and their parents. Saliva samples were collected from infants, mothers, and fathers on Days 1 and 2 (1/parent) for OT and cortisol measurement pre-SSC, during a 60-min SSC session, and a 45-min post-SSC. Parental anxiety was measured at the same time points. Parent–infant interaction was examined prior to discharge on Day 3 via video for synchrony and responsiveness using Dyadic Mutuality Coding.

Results:

Salivary OT levels increased significantly during SSC for mothers ( p < .001), fathers ( p < .002), and infants ( p < .002). Infant SC levels decreased significantly ( p < .001) during SSC as compared to before and after SSC. Parent anxiety scores were significantly related to parent OT and SC levels. Parents with higher OT levels exhibited more synchrony and responsiveness ( p < .001) in their infant interactions.

Conclusion:

This study addresses a gap in understanding the mechanisms linking parent–infant contact to biobehavioral responses. SSC activated OT release and decreased infant SC levels. Facilitation of SSC may be an effective intervention to reduce parent and infant stress in the NICU. Findings advance the exploration of OT as a potential moderator for improving responsiveness and synchrony in parent–infant interactions.

Impact of skin-to-skin contact on the autonomic nervous system in the preterm infant and his mother

Before, during and after mother-newborn skin-to-skin contact (SSC), parasympathetic activity was evaluated by heart rate variability (HRV) analysis. SSC had a favorable impact on maternal and premature infant parasympathetic activities with a more pronounced response for neonates when the basal HRV values were lower, without modifications of EDIN scores, temperatures or oxygen saturation.