Effect of early skin-to-skin contact following normal delivery on incidence of hypothermia in neonates more than 1800 g: randomized control trial

Elective extubation during skin-to-skin care in preterm newborns is safe and well-tolerated

AIM

To evaluate the safety and tolerance of elective extubations in preterm newborns (PNB) during skin-to-skin care (SSC) compared to those performed in an incubator.

METHODS

Retrospective observational study including 142 extubations in 93 PNB with gestational age (GA) <32 weeks and/or birth weight (BW) <1500 g performed during the first 2 months of life. Safety, tolerance and extubation success at 72 h were assessed.

RESULTS

The median GA was 25.4 weeks in the SSC group versus 26.6 weeks in the incubator group (p = 0.002). The median BW was 700 grams and 880 grams, respectively (p = 0.001). In total, 60 extubations (42.3%) were performed during SSC in 42 PNB and 82 in incubator in 69 PNB. No incidents related to extubation during SSC were recorded. The extubation success rate was 80% in SSC versus 79.3% in incubator (p = 0.915). Most failures occurred between 3 and 24 h after extubation. There were no observed differences in heart rate or FiO2 variations between the groups, nor in the need to escalate respiratory support at 24 h after extubation (SSC 15% vs. incubator 12.2%, p = 0.628).

CONCLUSION

Extubation during SSC is a feasible, safe and well-tolerated practice, while allowing PNB to experience the benefits from SSC.

Hypothermia in preterm infants admitted to low-resource neonatal units in northern Nigeria: an observational study of occurrence and risk factors

BACKGROUND

Hypothermia is an important cause of morbidity and mortality among preterm and low-birth-weight neonates. In resource-constrained settings, limited referral infrastructure and technologies for temperature control potentiate preterm hypothermia. While there is some documentation on point-of-admission hypothermia from single center studies, there are limited multicenter studies on the occurrence of hypothermia among preterm infants in resource-limited-settings. Therefore, we conducted a multicenter study to determine the prevalence and risk factors for hypothermia at the time of admission and during the first 72 h after admission in northern Nigeria.

METHOD

We carried out a prospective cohort study on preterm infants admitted to four referral hospitals in northern Nigerian between August 2020 and July 2021. We documented temperature measurements at admission and the lowest and highest temperatures in the first 72 h after admission. We also collected individual baby-level data on sociodemographic and perinatal history data. We used the World Health Organization classification of hypothermia to classify the babies' temperatures into mild, moderate, and severe hypothermia. Poisson regression analysis was used to identify risk factors for moderate-severe hypothermia.

RESULTS

Of the 933 preterm infants enrolled, 682 (72.9%) had hypothermia at admission although the prevalence of hypothermia varied across the four hospitals. During the first 24 h after admission, 7 out of every 10 babies developed hypothermia. By 72 h after admission, between 10 and 40% of preterm infants across the 4 hospitals had at least one episode of moderate hypothermia. Gestational age (OR = 0.86; CI = 0.82-0.91), birth weight (OR = 8.11; CI = 2.87-22.91), presence of a skilled birth attendant at delivery (OR = 0.53; CI = 0.29-0.95), place of delivery (OR = 1.94 CI = 1.13-3.33) and resuscitation at birth (OR = 1.79; CI = 1.27-2.53) were significant risk factors associated with hypothermia.

CONCLUSION

The prevalence of admission hypothermia in preterm infants is high and hypothermia is associated with low-birth-weight, place of delivery and presence of skilled birth attendant. The prevalence of hypothermia while in care is also high and this has important implications for patient safety and quality of patient care. Referral services for preterm infants need to be developed while hospitals need to be better equipped to maintain the temperatures of admitted small and sick newborns.

Skin-to-skin transfer from the delivery room to the neonatal unit for neonates of 1,500g or above: a feasibility and safety study

Objective

Immediate skin-to-skin contact (SSC) is already standard care for healthy term newborns, but its use for term or preterm newborns requiring admission to neonatal intensive care unit (NICU) with or without respiratory support is challenging. This study aimed to assess the safety and feasibility of SSC during the transfer of newborn infants, using a new purpose-built mobile shuttle care-station, called "Tandem".

Material and methods

A monocentric prospective observational study was conducted at the tertiary referral center of the Université libre de Bruxelles in Brussels, Belgium after ethical approval by Hopital Erasme's Ethics Committee (ClinicalTrials.gov ID: NCT06198478). Infants born with a birth weight above 1,500 g were included. Following initial stabilization, infants were placed in SSC with one of their parents and transferred to the NICU using the Tandem.

Results

Out of 65 infants initially included, 64 (98.5%) were successfully transported via SSC using the Tandem. One transfer was not successful due to last minute parental consent withdrawal. The median (range) duration of continuous skin-to-skin contact after birth was 120 min (10-360). SSC transfers were associated with gradually decreasing heart rate (HR) values, stable oxygen saturation levels (SpO2), and no increase in median fraction of inspired oxygen (FiO2). Heatloss was predominantly observed during initial setup of SSC. There was no significant difference in the occurrence of tachycardia, desaturation or hypothermia between preterm and term neonates. No equipment failures compromising the transfer were recorded.

Conclusion

Skin-to-skin transfer of infants with a birthweight of equal or above 1,500 g using the Tandem shuttle is feasible and associated with stable physiological parameters. This method facilitates early bonding and satisfies parents.

Clinical Trial Registration

ClinicalTrials.gov (NCT06198478).

Evidence-Based Consensus Recommendations for Skin Care in Healthy, Full-Term Neonates in India

Purpose

Neonatal skin care practices guided by personal experience and preferences might be substantially different across different hospital settings. The aim of this consensus recommendation is to provide clinical practice guidance to healthcare practitioners on evidence-based neonatal skin care practices from delivery-to-discharge, in hospital settings.

Patients and Methods

A Scientific Advisory Board meeting on "Evidence-based Neonatal Skin Care Practices and Protocols" was held in December 2020 with an expert panel comprising neonatologists, pediatricians, obstetricians and gynecologists and pediatric dermatologist. Comprehensive literature search was performed up to 23 March 2021 using PubMed and Google Scholar to retrieve relevant evidence.

Results

Recommendations were developed on critical aspects of skin care in healthy full-term neonates including cleansing at birth, skin-to-skin care, cord care, diaper area care, initial and routine bathing, cleansers and emollients use, and criteria to choose appropriate skin care products. Recommendations include inclusion of skin assessment in routine neonatal care, first bath timing after cardio-respiratory and thermal stabilization, 6-24 hours after birth; bathing with water alone or adding a mild liquid cleanser could be considered appropriate as it does not impact the developing skin barrier; use of emollients is recommended for neonates with higher risk of development of eczema to maintain and enhance skin barrier function and integrity; and inclusion of skin care advice in neonatal discharge checklist. Importance of rigorous quality control, high-quality clinical trials for assessment of baby products, usage of products that are formulated appropriately for newborns, and full label transparency for baby products were highlighted. The panel identified gaps in literature and discussed the scope for future research.

Conclusion

These recommendations may help to standardize evidence-based skin care for healthy full-term neonates in Indian hospital settings to improve the quality of care that neonates receive in hospital and facilitate improvement in overall neonatal health outcomes.

Immediate skin-to-skin contact versus care under radiant warmer at birth in moderate to late preterm neonates - A randomized controlled trial

OBJECTIVE

To compare the effect of immediate care at birth in skin-to-skin contact (SSC) or under a radiant warmer on cardiorespiratory stability at 60 minutes of age in moderate-to-late preterm neonates.

METHODS

In this open-label, parallel-group, randomized controlled trial, neonates born at 330/7 to 366/7 weeks of gestation by vaginal delivery and breathing or crying were randomized to receive care at birth in SSC (n = 50) or under a radiant warmer (n = 50). In the SSC group, immediate care at birth including drying and clearing of the airway was provided in SSC over the mother's abdomen. SSC was maintained for an observational period of 60 minutes after birth. In the radiant warmer group, care at birth and post-birth observation was performed under an overhead radiant warmer. The primary outcome of the study was the stability of the cardio-respiratory system in late preterm infants (SCRIP) score at 60 minutes of age.

RESULTS

Baseline variables were similar in the two study groups. The SCRIP score at 60 minutes of age was similar in the two study groups (median: 5.0, IQR: 5-6 vs. 5.0, 5-6). The mean axillary temperature at 60 minutes of age was significantly lower in the SSC group (°C; 36.4 ± 0.4 vs. 36.6 ± 0.4, P = 0.004).

CONCLUSION

It was feasible to provide immediate care at birth in moderate and late preterm neonates while being positioned in SSC with the mother. However, in comparison to care under a radiant warmer, this did not lead to better cardiorespiratory stability at 60 minutes of age.

TRIAL REGISTRATION

Clinical Trial Registry of India (CTRI/2021/09/036730).

Kangaroo mother care for preterm or low birth weight infants: a systematic review and meta-analysis

IMPORTANCE

The Cochrane review (2016) on kangaroo mother care (KMC) demonstrated a significant reduction in the risk of mortality in low birth weight infants. New evidence from large multi-centre randomised trials has been available since its publication.

OBJECTIVE

Our systematic review compared the effects of KMC vs conventional care and early (ie, within 24 hours of birth) vs late initiation of KMC on critical outcomes such as neonatal mortality.

METHODS

Eight electronic databases, including PubMed®, Embase, and Cochrane CENTRAL, from inception until March 2022, were searched. All randomised trials comparing KMC vs conventional care or early vs late initiation of KMC in low birth weight or preterm infants were included.

DATA EXTRACTION AND SYNTHESIS

The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered with PROSPERO.

MAIN OUTCOMES AND MEASURES

The primary outcome was mortality during birth hospitalization or 28 days of life. Other outcomes included severe infection, hypothermia, exclusive breastfeeding rates, and neurodevelopmental impairment. Results were pooled using fixed-effect and random-effects meta-analyses in RevMan 5.4 and Stata 15.1 (StataCorp, College Station, TX).

RESULTS

In total, 31 trials with 15 559 infants were included in the review; 27 studies compared KMC with conventional care, while four compared early vs late initiation of KMC. Compared with conventional care, KMC reduces the risks of mortality (relative risk (RR) 0.68; 95% confidence interval (CI) 0.53 to 0.86; 11 trials, 10 505 infants; high certainty evidence) during birth hospitalisation or 28 days of age and probably reduces severe infection until the latest follow-up (RR 0.85, 95% CI 0.79 to 0.92; nine trials; moderate certainty evidence). On subgroup analysis, the reduction in mortality was noted irrespective of gestational age or weight at enrolment, time of initiation, and place of initiation of KMC (hospital or community); the mortality benefits were greater when the daily duration of KMC was at least 8 hours per day than with shorter-duration KMC. Studies comparing early vs late-initiated KMC demonstrated a reduction in neonatal mortality (RR 0.77, 95% CI 0.66 to 0.91; three trials, 3693 infants; high certainty evidence) and a probable decrease in clinical sepsis until 28-days (RR 0.85, 95% CI 0.76 to 0.96; two trials; low certainty evidence) following early initiation of KMC.

CONCLUSIONS AND RELEVANCE

The review provides updated evidence on the effects of KMC on mortality and other critical outcomes in preterm and low birth weight infants. The findings suggest that KMC should preferably be initiated within 24 hours of birth and provided for at least 8 hours daily.

Early detection of cold stress to prevent hypothermia: A narrative review

Temperature monitoring is essential for assessing neonates and providing appropriate neonatal thermal care. Thermoneutrality is defined as the environmental temperature range within which the oxygen and metabolic consumptions are minimum to maintain normal body temperature. When neonates are in an environment below thermoneutral temperature, they respond by vasoconstriction to minimise heat losses, followed by a rise in metabolic rate to increase heat production. This condition, physiologically termed cold stress, usually occurs before hypothermia. In addition to standard axillary or rectal temperature monitoring by a thermometer, cold stress can be detected by monitoring peripheral hand or foot temperature, even by hand-touch. However, this simple method remains undervalued and generally recommended only as a second and lesser choice in clinical practice. This review presents the concepts of thermoneutrality and cold stress and highlights the importance of early detection of cold stress before hypothermia occurs. The authors suggest systematic clinical determination of hand and foot temperatures by hand-touch for early detection of physiological cold stress, in addition to monitoring core temperature for detection of established hypothermia, particularly in low-resource settings.

Impact of hypothermia alert device (BEMPU) on improvement of duration of Kangaroo Mother Care (KMC) provided at home: parallel-group randomized control trial

The objective of the study was to determine if using the hypothermia-detecting bracelet (named BEMPU) improves the duration of Kangaroo Mother Care (KMC) at home by one hour. This parallel-group randomized controlled trial was conducted at a step-down nursery of a teaching hospital. Neonates between 1000 and 2000 g were randomized to BEMPU and control groups at the time of discharge. BEMPU was applied at the wrist of each newborn in the BEMPU (intervention) group. Parents were advised to keep the BEMPU in place till 4 weeks post-discharge. The BEMPU generates a beep sound as an alarm when a newborn's temperature drops below 36.5 °C. Parents in both groups were trained to provide KMC at home. Parents in the BEMPU group received the "KMC chart" and "BEMPU beep chart," while the control group received the "KMC chart" only. In the "KMC chart," parents entered information about KMC hours on a real-time basis, and in the "BEMPU beep chart," they entered information about alarm beeps from BEMPU on a real-time basis till 4 weeks post-discharge. Independent samples t-test was used to compare mean KMC hours between the two groups. A total of 128 neonates participated in the study (64 in BEMPU and 64 in Control groups). The mean(SD) gestational age for the BEMPU group was 34.04(2.84) weeks vs 34.75(2.70) weeks for the control group. In BEMPU group, mean(SD) daily time spent doing KMC was significantly higher in 1st week [4.78(2.93) vs. 3.22(2.44) h, p = 0.003], in 2nd week [4.52(3.43) vs. 2.84(2.95) h, p = 0.008], in 3rd week [4.23(3.71) vs. 2.30(2.70) h, p = 0.003], in 4th week [3.72(3.30) vs. 1.95(2.65) h, p = 0.003] as compared to control group. BEMPU improved the daily duration of KMC hours at home compared to the control group over four weeks. Clinical Trial Registration: This trial is registered at Clinical Trials Registry India with registration number: CTRI/2018/08/015154 and accessible at http://ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=27600&EncHid=&modid=&compid=%27,%2727600det%27 Registered on 01/08/2018.

Efficacy of skin-to-skin vs. cloth-to-cloth contact for thermoregulation in low birth weight newborns: a randomized crossover trial

OBJECTIVE

Skin-to-skin contact (SSC) is effective to maintain normal temperature in low birth weight (LBW) newborns. However, there are several barriers related to privacy and space availability for its optimum utilization. We used cloth-to-cloth contact (CCC), i.e. placing the newborn in Kangaroo position without removing cloths as an innovative alternative to SSC to test its efficacy for thermoregulation and feasibility as compared to SSC in LBW newborns.

METHODS

The newborns eligible for Kangaroo Mother Care (KMC) in step-down nursery were included in this randomized crossover trial. Newborns received SSC or CCC as per randomization on the first day and then crossed over to other group on the next day and so on. A feasibility questionnaire was asked to the mothers and the nurses. Axillary temperature was measured at various time intervals. Group comparisons were made by either using independent sample t-test or Chi-square test.

RESULTS

A total of 23 newborns received KMC for total 152 occasions in the SSC group and 149 times in the CCC group. There was no significant temperature difference between the groups at any time-point. Mean (standard deviation) gain of temperature at 120 min in the CCC group [0.43 (0.34)°C] was comparable to the SSC group [0.49 (0.36)°C] (p = 0.13). We did not observe any adverse effect of CCC. Most mothers and nurses perceived CCC feasible in hospital settings and felt that it could be feasible in-home settings too.

CONCLUSION

CCC was safe, more feasible and not inferior to SSC for maintaining thermoregulation in LBW newborns.

Effect of Kangaroo Mother Care on Cerebral Hemodynamics in Preterm Neonates Assessed by Transcranial Doppler Sonography in Middle Cerebral Artery

OBJECTIVE

To study the effect of KMC in premature newborns on cerebral hemodynamics in the middle cerebral artery (MCA) using transcranial doppler sonography.

METHODS

In this descriptive study, 40 clinically stable preterm neonates admitted to the neonatal intensive care unit of our institute and undergoing Kangaroo mother care (KMC) were enrolled. Physiological and cerebral blood flow parameters of MCA were obtained by using transcranial doppler sonography at baseline, at 60 minutes of KMC, and after 60 minutes of stopping KMC.

RESULTS

Of the 40 enrolled neonates (24 males), the mean (SD) birth weight, gestation age, and postnatal age were 1698.25 (495.44) g, 33.00 (1.67) wk, and 6.80 (4.51) days, respectively. The mean (SD) cerebral blood flow velocities increased (peak systolic velocity (PSV), P=0.03; end diastolic velocity, P<0.001; mean velocity, P<0.001) and doppler indices decreased (resis-tive index, P=0.001; pulsatility index, P<0.001) significantly; whereas, heart rate (P<0.001) decreased but SpO2 (P=0.001) and mean blood pressure (P=0.003) increased significantly at 60 minutes of KMC as compared to baseline. Sixty minutes after stopping KMC, all parameters (except PSV) were higher than baseline, indicating post KMC effect.

CONCLUSION

KMC improves cerebral hemodynamics in clinically stable preterm neonates.

Antenatal and delivery practices and neonatal mortality amongst women with institutional and non-institutional deliveries in rural Zimbabwe: observational data from a cluster randomized trial

BACKGROUND

Despite achieving relatively high rates of antenatal care, institutional delivery, and HIV antiretroviral therapy for women during pregnancy, neonatal mortality has remained stubbornly high in Zimbabwe. Clearer understanding of causal pathways is required to inform effective interventions.

METHODS

This study was a secondary analysis of data from the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial, a cluster-randomized community-based trial among pregnant women and their infants, to examine care during institutional and non-institutional deliveries in rural Zimbabwe and associated birth outcomes.

RESULTS

Among 4423 pregnant women, 529 (11.9%) delivered outside a health institution; hygiene practices were poorer and interventions to minimise neonatal hypothermia less commonly utilised for these deliveries compared to institutional deliveries. Among 3441 infants born in institutions, 592 (17.2%) were preterm (< 37 weeks gestation), while 175/462 (37.9%) infants born outside health institutions were preterm (RR: 2.20 (1.92, 2.53). Similarly, rates of stillbirth [1.2% compared to 3.0% (RR:2.38, 1.36, 4.15)] and neonatal mortality [2.4% compared to 4.8% (RR: 2.01 1.31, 3.10)] were higher among infants born outside institutions. Among mothers delivering at home who reported their reason for having a home delivery, 221/293 (75%) reported that precipitous labor was the primary reason for not having an institutional delivery while 32 (11%), 34 (12%), and 9 (3%), respectively, reported distance to the clinic, financial constraints, and religious/personal preference.

CONCLUSIONS

Preterm birth is common among all infants in rural Zimbabwe, and extremely high among infants born outside health institutions. Our findings indicate that premature onset of labor, rather than maternal choice, may be the reason for many non-institutional deliveries in low-resource settings, initiating a cascade of events resulting in a two-fold higher risk of stillbirth and neonatal mortality amongst children born outside health institutions. Interventions for primary prevention of preterm delivery will be crucial in reducing neonatal mortality in Zimbabwe.

TRIAL REGISTRATION

The trial is registered with ClinicalTrials.gov, number NCT01824940.

Clinical practice guideline for kangaroo mother care in preterm and low birth weight infants

Kangaroo mother care has reduced mortality and morbidity in preterm and low birth weight infants and has many benefits, such as promoting breastfeeding. Based on the current evidence in China and international, we developed a clinical practice guideline for kangaroo mother care in preterm and low birth weight infants using the Grading of Recommendations, Assessment, Development and Evaluation and proposed 34 recommendations for 20 key questions. Our goal is to promote the appropriate implementation of kangaroo mother care in clinical practice.

Identifying additional risk factors for early asymptomatic neonatal hypoglycemia in term and late preterm babies

BACKGROUND

Neonatal hypoglycemia is a common metabolic disorder in newborns, which may present with non-specific symptoms or even be asymptomatic. Current guidelines recommend screening for hypoglycemia in at-risk babies (late preterm, small for gestational age, large for gestational age, and infants of diabetic mothers). Past studies have suggested other potential risk factors, such as maternal obesity, gestational hypertension, cesarean section, etc. In this study, we aim to identify additional prenatal and perinatal maternal/fetal characteristics associated with early asymptomatic hypoglycemia in term and late preterm babies.

METHODS

We performed a retrospective review on medical charts of all newborns, born between January, 2017 and December, 2020, in the well-baby newborn nursery of a tertiary medical center. We identified newborns who had received blood glucose concentration monitor after birth. Detailed prenatal and perinatal maternal/newborn information were collected for analysis.

RESULTS

In the study period, 841 newborns had received blood glucose screening after birth. After matching by sex and indication for postnatal blood glucose screen (SGA, LGA, and GDM), 148 newborns were included in the "hypoglycemia group" and 296 newborns were included in the "euglycemia group". In the univariate analysis, parity, insulin treatment for gestational diabetes mellitus (GDM), and cesarean section were associated with an increased risk for neonatal hypoglycemia. Factors associated with decreased risk included higher gestational age, longer duration of skin-to-skin contact, neonatal hyperthermia, higher maternal labor pain score, and epidural anesthesia administration. By multivariable analysis, insulin treatment for GDM was identified as an independent factor associated with increased risk for neonatal hypoglycemia.

CONCLUSION

Our study showed insulin treatment for GDM to be independently associated with neonatal hypoglycemia. Other risk factors noted in the univariate analysis, such as decreased skin-to-skin contact duration, hypothermia, Cesarean section, and preterm delivery, would require further investigation to confirm the findings.

Duration of skin-to-skin care and rectal temperatures in late preterm and term infants

Background

Hypothermia during the newborn period is widely regarded as a major contributory cause of significant morbidity and mortality of newborn infants. Thermoprotective behaviours such as skin-to-skin care (SSC) or the use of appropriate devices have been recommended as simple tools for the avoidance of neonatal hypothermia. We examined the relation between the duration of skin-to-skin care and infant temperature change after birth in suboptimal delivery room temperatures.

Methods

We reviewed the medical charts of all vaginally born infants of gestational age ≥ 35 weeks born January-July 2018 and admitted to the well-baby nursery. After SSC was discontinued, the infant’s rectal temperature was measured to determine the frequency and severity of hypothermia.

Results

The charts of 688 vaginally born infants were examined. Our mean delivery room temperature was 21.7 (SD 2.2) °C, well below the WHO recommendation of 25 °C. After SSC 347 (50.4%) infants were normothermic (temperature 36.5–37.5 °C), 262 (38.0%) were mildly hypothermic (36.0-36.4 °C), and 79 (11.4%) were moderately hypothermic (32.0-35.9 °C). The mean skin-to-skin time in infants was 63.9 (SD 20.9) minutes. SSC duration was associated with increase in rectal temperature for patients of gestational ages ≥ 38 weeks and with decrease in rectal temperature in patients of gestational age < 38 weeks.

Conclusion

SSC is effective, even at suboptimal delivery room temperatures, for promoting normothermia in infants of ≥ 38 weeks’ gestation but may not provide adequate warmth for infants of < 38 weeks.

Early Interventions to Achieve Thermal Balance in Term Neonates

Hypothermia is one of the most recognized and potentially avoidable reasons for transfer of a term neonate to the NICU. Physiologic and physical factors involved in the loss of heat affect a neonate's ability to thermoregulate in extrauterine environments. At the same time, these processes are interdependently affected by hypothermia, hypoglycemia, and respiratory distress. Underlying principles and preventive measures to avoid hypothermia are presented with practical application to practice. The implementation of best practices will decrease NICU admissions that separate mothers and neonates at this critical time. Preventive measures, competent assessment guides, and early interventions offer measures to avert avoidable hypothermia-related admissions to the NICU.

Optimising homeothermy in neonates: A systematic review and clinical guidelines from the French Neonatal Society

AIM

Thermal instability is harmful on the newborn infant. We sought to draw up practical guidelines on maintaining homeothermy alongside skin-to-skin contact.

METHODS

A systematic analysis of the literature identified relevant studies between 2000 and 2021 in the PubMed database. Selected publications were evaluated, and their level of evidence was graded, in order to underpin the development of clinical guidelines.

RESULTS

We identified 7 meta-analyses and 64 clinical studies with a focus on newborn infants homeothermy. Skin-to-skin contact is the easiest and most rapidly implementable method to prevent body heat loss. Alongside skin-to-skin contact, monitoring the newborn infant's body temperature with a target of 37.0°C is essential. For newborn infants <32 weeks of gestation, a skullcap and a polyethylene bag should be used in the delivery room or during transport. To limit water loss, inhaled gases humidification and warming is recommended, and preterm infants weighing less than 1600 g should be nursed in a closed, convective incubator. With regard to incubators, there are no clear benefits for single- versus double-wall incubators as well as for air versus skin servo control.

CONCLUSION

Alongside skin-to-skin contact, a bundle of practical guidelines could improve the maintenance of homeothermy in the newborn infant.

Impact of "natural" cesarean delivery on peripartum blood loss: a randomized controlled trial

BACKGROUND

Early skin-to-skin contact after vaginal delivery increases milk production and may increase oxytocin release, leading to a reduction in the rate of postpartum hemorrhage.

OBJECTIVE

This study aimed to examine the effect of "natural" cesarean deliveries on perioperative maternal blood loss.

STUDY DESIGN

This was a randomized controlled trial conducted at a single university-affiliated medical center, between August 2016 and February 2018. Term singleton pregnancies scheduled for a planned cesarean delivery under spinal anesthesia were included. Women were randomized at a ratio of 1:1 to natural cesarean delivery (study group) or traditional cesarean delivery (control group) during the routine preoperative assessment. Women in the study group watched fetal extraction, had early skin-to-skin contact, and breastfed until the end of surgery. Neonates in the control group were presented to the mother for a few minutes. Blood samples were drawn from all women, during fascia closure, to determine oxytocin levels using an enzyme-linked immunosorbent assay kit. The laboratory component was performed after recruitment completion and was accomplished in February 2019. The primary outcome was postpartum hemoglobin levels. To detect a difference of 0.5 g/dL between the groups with α=0.05 and β=80%, 214 women were needed.

RESULTS

Of 214 randomized women, 23 were excluded. There was no difference in demographic and obstetrical variables between the groups. Postpartum hemoglobin levels were 10.1±1.1 and 10.3±1.3 g/dL in the study and control groups, respectively (P=.19). There was no difference in the rates of postpartum hemorrhage and blood transfusion. Maternal pain scores, satisfaction, and exclusive breastfeeding were comparable. Maternal oxytocin blood levels were 389.5±183.7 and 408.5±233.6 pg/mL in the study and control groups, respectively (P=.96). The incidence of neonatal hypothermia was comparable between the groups (P=.13).

CONCLUSION

Natural cesarean delivery did not affect perioperative hemoglobin level or maternal oxytocin blood concentration.

Systematic review confirmed the benefits of early skin-to-skin contact but highlighted lack of studies on very and extremely preterm infants

AIM

We systematically reviewed the literature to identify the benefits of early skin-to-skin contact (SSC) for all gestational ages.

METHODS

The MEDLINE, Embase and CINAHL databases were searched for papers published in English from 1 January 1975 to 31 March 2020. Early SSC was defined as when the infant was placed directly onto the mother's chest within 180 min of birth. Two authors independently searched the databases, appraised study quality and extracted the study design and outcome data. The primary outcomes were the infants' physiological stability after birth: thermoregulation and stabilisation. The secondary outcomes were exclusive breastfeeding and mother-infant interaction.

RESULTS

We reviewed 30 studies that assessed the benefits of early SSC: 22 comprised term-born healthy infants and eight focused on preterm or ill infants. These included various gestational ages, birth methods and cultural backgrounds. The studies demonstrated that early SSC stabilised neonatal physiological parameters, promoted exclusive breastfeeding and supported bonding. Most of the data were from term and late preterm births.

CONCLUSION

This systematic review showed that early SSC could be beneficial. Further studies that focus on providing very and extremely preterm infants with SSC, and parental experiences, are needed to enable SSC to be adopted as routine practice.

Increasing Early Skin-to-Skin in Extremely Low Birth Weight Infants

BACKGROUND

Early skin-to-skin care (SSC) has been shown to improve outcomes after preterm birth, including improved clinical stability and establishment of breastfeeding. Recent evidence suggests the most unstable infants get the most benefit, yet these infants are not consistently offered opportunities for SSC because of safety concerns and discomfort of the care team.

PURPOSE

To identify barriers and implement a multidimensional approach to increase SSC within the first 72 hours of life among infants born less than 28 weeks' gestation and less than 1,000 g in a Level IV university-based regional intensive care nursery.

METHODS

Using Institute of Healthcare Improvement quality improvement methodology, a multidisciplinary team identified barriers to SSC and developed targeted interventions, including a unit-specific protocol; widespread parent, staff, and provider education; and an infant readiness checklist. The primary outcome was the rate of SSC within 72 hours. The balancing measure was the rate of severe intraventricular hemorrhage (IVH). Data were collected from monthly chart review and analyzed with statistical process control charts. The aim was to increase SSC within 72 hours of birth from 7 percent to greater than 80 percent within 12 months for infants born less than 28 weeks' gestation or less than 1,000 g.

RESULTS

Between June 2017 and December 2019, there were 52 extremely preterm infants included in the project (15 preintervention and 37 postintervention). The rate of SSC within the first 72 hours increased from 7 to 84 percent. There has been no increase in any or severe IVH during the project period despite the increased rate of SSC.

IMPLICATIONS FOR PRACTICE

Implementation of multidimensional, multidisciplinary interventions for reducing barriers to early SSC in extremely preterm infants resulted in rapid adoption of SSC in the first 72 hours of life without increasing severe IVH in this high-risk population.

A quality improvement initiative to reduce hypothermia in a Baby-Friendly nursery - our story of algorithms, K-cards, and Key cards

BACKGROUND

Baby-Friendly hospitals encourage rooming-in newborns with mothers. In our institution, we noticed increased incidence of hypothermia following Baby-Friendly designation. We aimed to reduce the incidence of hypothermia in the mother-baby-unit to <15% and to decrease the rate of isolated hypothermia admissions to the neonatal intensive care unit (NICU) by 20% over two years.

METHODS

After a retrospective review of newborns ≥35 weeks gestation in the mother-baby-unit with hypothermia, we implemented multiple interventions such as nursing education, hypothermia algorithm, Kamishibai cards, and Key cards.

RESULTS

Hypothermia incidence in the mother-baby-unit decreased from 20.9 to 14.5% (p < 0.001) and infants requiring NICU admission decreased by 71% (p < 0.001) following all interventions. Apart from nursing education, all interventions led to significant reductions in both outcomes from baseline.

CONCLUSION

Instituting a hypothermia algorithm and utilizing K-cards and Key cards reduces the incidence of hypothermia in the mother-baby-unit and NICU admissions for isolated hypothermia.

Heart-rate agreement between ECG and a new, wireless device during early skin-to-skin contact

AIM

To assess the agreement of heart rate (HR) between the new device - a fabric jacket for neonates, with integrated sensors detecting ECG signals and a Bluetooth connection to a computer (ComfTech, HOWDY) - and the clinical reference, ECG, during the skin-to-skin contact (SSC) in the first 2 h after birth, for the potential use of early detection of Sudden and Unexpected Postnatal Collapse (SUPC).

METHODS

We enrolled newborns ≥35⁺⁰  weeks of gestation, with Apgar score >8 at 5 min in a prospective, observational study in the delivery room, excluding infants with need for resuscitation, clinical instability or major malformations. We assessed HR within 20 min after birth by both devices simultaneously: the index test ComfTech HOWDY and the standard ECG (Vita Guard VG 3100, Getemed). We compared HR between the two methods at 0, 15, 30, 45, 60, 90 and 120 min by the Bland-Altman plot.

RESULTS

We included 60 infants. The mean difference between the methods was -1.3 bpm, 95%LoA -12.4 to 9.7 bpm. Spearman rank correlation coefficient ρ = -0.06.

CONCLUSION

ComfTech HOWDY presents reliable agreement with the ECG and might assist in identifying infants at risk for SUPC.

Continuous pulse oximetry during skin-to-skin care: An Australian initiative to prevent sudden unexpected postnatal collapse

AIM

To examine the use of continuous pulse oximetry monitoring (CPOM) of newborns as a non-invasive and non-intrusive standard of care for promoting early and safe skin-to-skin contact between mothers and newborns immediately after birth and to gather acceptability feedback from midwifery staff and mothers.

METHODS

All babies receiving skin-to-skin contact (SSC) had continuous pulse oximetry monitoring (CPOM) for the first-hour postbirth. Staff were trained with education sessions before implementation. Midwives and mothers were surveyed post-implementation and again after distribution of an education brochure regarding CPOM.

RESULTS

Seventy per cent of midwives and 66% of mothers responded to the survey. The majority of midwives received the practice positively and felt reassured by the use of CPOM in the immediate postpartum period. The survey identified gaps in maternal knowledge of the risk and benefits of SSC which improved significantly after the distribution of the educational brochure (P = .01).

CONCLUSION

Continuous pulse oximetry monitoring with a compact monitor in the first-hour postbirth is a simple, non-invasive and innovative approach to enhance safe skin-to-skin care by improving vigilance of newborns. Our study confirmed the acceptance of such approach by midwives and mothers in our population.

Embrace versus Cloth Wrap in preventing neonatal hypothermia during transport: a randomized trial

BACKGROUND

We assessed the efficacy of Embrace Nest Infant Warmer versus Cloth Wrap in preventing hypothermia during short-term transport from the emergency department (ED) to the neonatal intensive care unit (NICU).

METHODS

Neonates weighing ≥1500 g coming to the ED were randomized for transport to the NICU. Axillary temperature was measured.

RESULTS

A total of 120 newborns (60 per group) were enrolled. From ED exit to NICU entry, the mean (SD) temperature increased in the Embrace group by 0.37 °C (0.54), whereas it reduced by 0.38 °C (0.80) in the Cloth group (p < 0.001). Hypothermia cases reduced in the Embrace group from 39 (65%) to 21 (35%), while it increased from 21 (35%) to 39 (65%) in the Cloth group (p = 0.001) from ED exit to NICU entry. The thermoregulation for 24 h after admission to the NICU was superior in the Embrace group.

CONCLUSIONS

Embrace showed significantly better thermoregulation in neonates. Further studies should be done to measure its effectiveness in different environments and distances.

Post-Partum Skin-to-Skin Care and Infant Safety: Results of a State-Wide Hospital Survey

Objectives. Survey current experience with Skin to Skin care (SSC) in Pennsylvania Maternity Centers. Study Design. The nursing director of each Maternity Center in PA (n = 95) was sent an on-line confidential survey querying SSC practices. Responses were compared by delivery size, location, and nature of affiliation. Statistics analyzed by chi-square and student t-test. Results. Of these 64/95 MCs (67%) responded. All allowed SSC after vaginal deliveries, 55% after C-section, 73% mother's room. Monitoring included delivery room nurse (94%) with support from other providers (61%), family members (37%), and electronic monitoring (5%). If SSC occurred in mother's room all reported family education on safe practices. 40% were aware of adverse SSC events, including falls and suffocation. About 80% educated staff about infant safety during SSC. Conclusions. Gaps in education and supervision during SSC were identified. Additional education and standardization of best practices are needed to reduce risks from falls and suffocation during SSC.

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.

Innovation in Practice: Preparing Doulas to Support Cesarean Births

Despite growing initiatives to support patient-centered labor and birth care, implementation of this care in the operating room is still limited. Doulas can be utilized in the operating room to facilitate evidence-based practices such as skin-to-skin contact for patients and newborns during cesarean birth. This article evaluates a curriculum and training method that was developed to educate doulas to provide safe and effective care during the cesarean birth experience. This intervention was found to be effective at improving doulas' self-perceived confidence in skills essential to support cesarean births and may serve as a model for other institutions to address barriers to the implementation of patient-centered evidence-based care in the operating room.

The newborn infant's thermal environment in the delivery room when skin-to-skin care has to be interrupted

OBJECTIVE

Newborns are prone to hypothermia immediately following birth. Hypothermia is associated with increased morbidity and mortality rates. We sought to assess the thermal environment and metabolic costs associated with exposure to various situations in the delivery room when skin-to-skin care (SSC) has to be curtailed.

METHODS

Environmental variables (air temperature: T _a; relative humidity: RH; radiative temperature: T _r; and air convection velocity) were recorded during sequences reproducing SSC, in the maternity unit's various rooms ("passive environments") and in incubators ("active environments"). Analytical calorimetry was then used to calculate the body heat loss (BHL) from these data.

RESULTS

The analysis of 1280 measurements of T _a, RH, T _r, and air convection velocity in SSC, passive and active environments revealed that (i) the thermohygrometric environment during SSC was optimal (T _a: 32.7 ± 3.2 °C; RH: 50.9 ± 5.6%), (ii) BHL rose when SSC had to be interrupted, and (iii) the use of a radiant incubator prevented hypothermia and reduced dry BHL but not humid BHL (9.4 ± 1.5 kcal/kg/h; p < .001), relative to SSC (5.8 ± 2.0 kcal/kg/h; p < .001).

CONCLUSION

The newborn infant's thermohygrometric environment is optimal during SSC in the delivery room. When SSC was interrupted, T_a and RH always decreased, and BHL increased in all passive environments.

Neonatal Hypothermia and Associated Factors among Newborns Admitted in the Neonatal Intensive Care Unit of Dessie Referral Hospital, Amhara Region, Northeast Ethiopia

Introduction

Neonatal hypothermia is the reduction in the body temperature of the newborn (less than 36.5°C). It is a global problem in neonates born both at hospitals and homes, but it showed a higher prevalence in developing countries (>90%). Although hypothermia is rarely a direct cause of death, it contributes to a substantial proportion of neonatal mortality globally.

Objective

To assess neonatal hypothermia and associated factors among newborns admitted in the NICU of Dessie Referral Hospital.

Methods and Materials

An institution-based cross-sectional study was conducted from March 15 to May 30, 2018. The data was collected from the mother and the chart of the newborn using a semistructured questionnaire. Data were cleaned, coded, and entered in EPI-info version 7.1.2.0 then exported to Statistical Package for Social Sciences (SPSS) version 20 software for analysis. Descriptive statistics were used to summarize the data. Bivariate and multivariate logistic regression and crude and adjusted odds ratio with their 95% confidence interval were computed. Finally, p value < 0.05 was used to identify variables that had a significant association with neonatal hypothermia.

Result

The proportion of neonatal hypothermia in the study area was 66.8%. Preterm delivery (AOR = 2.6, 95% CI: 1.1, 6.2), no skin-to-skin contact within 1 hour of delivery (AOR = 3.0, 95% CI: 1.3, 7.8), delivered at night time (AOR = 2.0, 95% CI: 1.02, 4.0), and neonates who had resuscitation (AOR = 2.9, 95% CI: 1.1, 7.2) showed significant association with neonatal hypothermia.

Conclusion

In this study, the proportion of hypothermia was high. Preterm delivery, no skin-to-skin contact within 1 hour, night-time delivery, and having resuscitation were significantly associated with neonatal hypothermia. Therefore, special attention is needed for the thermal care of preterm neonates and neonates delivered at night time. Furthermore, there should be strict adherence to cost-effective thermal care recommendations like warm resuscitation and skin-to-skin contact.

The nine stages of skin-to-skin: practical guidelines and insights from four countries

Incorporating systematic evidence with clinical expertise is a key element in the quest to improve quality of care and patient outcomes. The evidence supporting skin‐to‐skin contact in the first hour after birth is robust and includes significantly improved outcomes for both mother and infant. This paper compares available iterative data about newborn behaviour in the first hour after birth to further describe the observable behaviour pattern and to provide clinical insight for further research. Although the evidence for positive outcomes through skin‐to‐skin contact are robust, there is a dearth of research specifically focused on clinical practice. The methodology considers the four available data sets that used Widström's 9 stages, which consists of studies from Japan, Sweden, Italy and the United States, examining the parameters of each stage across settings from around the world. This research provides an expanded understanding of the timing of the newborn's progression through Widström's 9 observable stages. We found that newborns in all four data sets began with a birth cry and continued through the remaining stages of relaxation, awakening, activity, rest, crawling, familiarization, suckling and sleeping during the first hours after birth and consolidated the data into a Sign of the Stages chart to assist in further research. The evidence supports making a safe space and time for this important newborn behaviour. Clinical practices should encourage and protect this sensitive period.

Blinded randomized crossover trial: Skin-to-skin care vs. sucrose for preterm neonatal pain

OBJECTIVE

To compare skin-to-skin care (SSC) and oral sucrose for preterm neonatal pain control.

METHODS

Preterm neonates (28-36 weeks gestation) requiring heel-stick were eligible. In group-A, SSC was given 15-min before first heel-stick, and sucrose was given 2-min before second heel-stick. In group-B, the sequence was reversed. Blinded premature infant pain profile (PIPP) score assessment was done at 0, 1, and 5-min of heel-stick by two assessors.

RESULTS

A hundred neonates were enrolled. The inter-rater agreement for the PIPP score was good. The behavior state component was significantly lower in the sucrose group at all assessment points. The mean (SD) difference between 1-min and 0 min was similar [SSC 3.58(3.16) vs. sucrose 4.09(3.82), p = 0.24] between groups. The PIPP score attained baseline values at 5-min in both groups.

CONCLUSION

Albeit sucrose indicated instantaneous action, SSC and sucrose have comparable clinical efficacy for preterm neonatal pain control. Multisensory stimulation with SSC may result in a higher behavioral state component of the PIPP score.

Dealing with neonatal emergencies in low-resource settings

We describe the development and delivery of neonatal care including trends and impacts of major interventions on neonatal mortality particularly in low-resource settings. Low- and middle-income countries continue to be major contributors to neonatal mortality. Although there has been progress in reducing neonatal mortality, neonatal deaths are contributing an increasing percentage of childhood mortality. Several interventions targeting neonatal care such as neonatal resuscitation and essential newborn care have contributed to improved outcomes. However, there are still many neonatal deaths that are preventable with known effective interventions. This review addresses interventions proven effective in reducing neonatal mortality, challenges to implement them, and future directions of implementing these interventions in low- and middle-income countries.

Evidências sobre prevenção de lesões de pele em recém-nascidos: revisão integrativa

Objetivo: identificar estratégias para a prevenção de lesões de pele em recém-nascidos (RN) hospitalizados, publicadas em periódicos científicos no período de 2013 a 2018. Método: revisão integrativa de literatura realizada em dois momentos de busca em bases de dados, sendo selecionados 37 estudos publicados entre os anos de 2013 e 2018. Resultados: termorregulação, uso de antisséptico, uso de emolientes e limpeza do coto umbilical foram as recomendações mais encontradas. Entre as práticas baseadas em evidência, destacam-se as que previnem o risco de hipotermia, como o uso de saco de polietileno e o contato pele a pele, que respaldam a assistência e que garantem segurança no cuidado do paciente neonatal. Conclusão: a prevenção de lesões de pele é um tema relevante, entretanto, existe escassez de evidências robustas para sustentar, com segurança, as práticas de cuidados com o RN. Observa-se ainda que as evidências são insuficientes para englobar o universo do tema, demonstrando que o cuidado com a pele é um tema que demanda investimentos e mais pesquisas.

Evidence on prevention of skin lesions in newborns: integrative review

Objective: To identify strategies for the prevention of skin lesions in hospitalized newborns (NBs), published in scientific journals from 2013 to 2018. Method: Integrative literature review performed in two moments of database search, selecting 37 studies published between 2013 and 2018. Results: Thermoregulation, use of antiseptic, use of emollients and cleaning of the umbilical stump were the most commonly found recommendations. Among the evidence-based practices, we highlight those that prevent the risk of hypothermia, such as the use of a polyethylene bag and skin-to-skin contact, which support the assistance and ensure safety in the care of the neonatal patient. Conclusion: The prevention of skin lesions is a relevant topic. However, there is a scarcity of robust evidence to safely sustain NB care practices. It is also observed that the evidence is insufficient to encompass the universe of the theme, demonstrating that skin care is a theme that requires investment and more research.

Volunteer doulas' experiences supporting cesarean births: A qualitative analysis for preliminary program evaluation

BACKGROUND

Cesarean birth is common in the United States and associated with increased incidence of medical complications and maternal dissatisfaction. Doula support is associated with improved maternal and newborn outcomes but is often restricted to vaginal birth. The aim of this scoping study was to explore the experiences of volunteer doulas who provide support to women during cesarean birth.

METHODS

Qualitative study using semi-structured interviews with nine doula volunteers from one program to assess their experiences caring for clients in the operating room (OR).

RESULTS

Doulas described their experiences supporting cesarean births in relation to four different relationship-level themes, relationships between: doulas and their clients (and clients' support persons); doulas and the physical environment (OR, labor and delivery unit); doulas and the OR interprofessional team; and doulas and the program culture. Doulas described perceived strengths and weaknesses of the OR-based program, and suggested improvements and future development opportunities.

CONCLUSION

Doulas volunteering within this program highly valued their perceived role in the care of women experiencing cesarean birth, including reports of increasing evidence-based practices such as SSC and early breastfeeding initiation in the OR. These doulas reported successfully working around the physically challenging OR environment and alongside the cesarean interprofessional team.

Prevalence and factors associated with neonatal hypothermia on admission to neonatal intensive care units in Southwest Ethiopia - A cross-sectional study

INTRODUCTION

Neonatal hypothermia is one of the main underlying factors associated with neonatal deaths.

OBJECTIVE

The objective of this study was to assess the prevalence and factors associated with neonatal hypothermia on admission to neonatal intensive care units in Southwest Ethiopia.

METHODS

Institution-based cross-sectional study design was employed between February to September 2017 at intensive care units of Arba Minch and Jinka General Hospitals. All neonates admitted to the two neonatal intensive care units during the study period were included in the study. Data were collected by four nurses who were working in the units of the hospitals through semi-structured pre-tested questionnaire and checklist. Multi-variable logistic regression was used to analyze the relationship between the dependent and independent variables using odds ratio with a confidence interval of 95% and a p-value of 0.05.

RESULTS

The prevalence of neonatal hypothermia on admission to the neonatal intensive care units in this study area was 50.3%. Admission weight below 2500 gm. (AOR = 3.61, 95% CI: 2.10, 6.18), delay in initiation of breastfeeding (AOR = 2.42, 95% CI: 1.45, 4.02), early bathing (AOR = 2.63, 95% CI: 1.23, 5.63), admissions during cold season (AOR = 1.72, 95% CI: 1.04, 2.84), and presence of obstetrical complication(s) during pregnancy/labor (AOR = 2.46, 95% CI: 1.07, 5.66) were factors significantly associated with hypothermia on admission to the neonatal intensive care units.

CONCLUSIONS

The prevalence of neonatal hypothermia on admission to the intensive care units was high. There is a need to create awareness among the community members about the dangers of early bathing and late initiation of breastfeeding. It is also important to give attention to the newborns of mothers with obstetric complications, low-birth-weight babies and babies delivered during the cold season.

Effect of forced-air warming system in prevention of postoperative hypothermia in elderly patients: A Prospective controlled trial

BACKGROUND

Postoperative hypothermia in elderly patients is a well-known serious complication as it impairs wound healing, induces coagulopathy, increases the risk of blood loss, enhances oxygen consumption, and precipitates cardiac arrhythmias. We conducted this randomized controlled trial to evaluate the effect of a forced-air warming system on rewarming elderly patients undergoing total knee or hip arthroplasty.

METHODS

We recruited 243 elderly patients undergoing total knee or hip arthroplasty between May and December 2016. They were divided into three groups according to a computer-generated randomization table: group C (n = 78, rewarmed with only a regular blanket), group F1 (n = 82, rewarmed with a forced-air warming system set at 38°C), and group F2 (n = 83, rewarmed with a forced-air warming system set at 42°C). The nasopharyngeal temperature was recorded every 5 min for the first half hour, then every 10 min up to the end of the PACU (postanesthesia care unit) stay. The primary outcome was the rewarming time. The rewarming rate, increase in nasopharyngeal temperature (compared to the start of rewarming), hemodynamics, recovery time, and incidences of adverse effects were recorded.

RESULTS

No significant differences were found among the three groups in terms of the baseline clinical characteristics, use of narcotic drugs, intraoperative temperature, and hemodynamics (P > .05). Compared with the elderly patients in groups C and F1, both the heart rate and mean arterial pressure of those in group F2 were significantly increased 20 min after arrival at the PACU (P < .05). Patients in group F2 had the shortest rewarming time (35.89 ± 6.45 min, P < .001), highest rewarming efficiency (0.028 ± 0.001°C/min, P < .001), and fastest increased nasopharyngeal temperature among the three groups. Moreover, the elderly patients in group F2 had lower incidences of arrhythmia and shivering (P < .05).

CONCLUSIONS

The use of a forced-air warming system set at 42°C was shown to be the most effective way of rewarming elderly patients with postoperative hypothermia.

Efficacy of Polyethylene Skin Wrapping in Preventing Hypothermia in Preterm Neonates (<34 Weeks): A Parallel Group Non-blinded Randomized Control Trial

OBJECTIVE

The objective of this study was to determine the efficacy of polyethylene skin wrapping on thermoregulation in preterm neonates.

METHODS

Total 151 neonates were enrolled in this randomized control trial. In the control group, neonates were transferred to the radiant warmer and covered with warm cloth after initial care. In the study group, neonates were transferred to the radiant warmer and placed in a food-grade polyethylene bag for 1 h. Axillary temperature of all neonates was recorded for first 24 h at frequent time intervals.

RESULTS

Mean temperature reached to normal range earlier and remained significantly higher in the study group for most time intervals, and this difference persisted even at 24 h. Significantly less number of preterm newborns suffered from hypothermia in the study group as compared with the control group [50 (67.6%) vs. 67 (87%), p = 0.004].

CONCLUSIONS

Polyethylene wraps achieved rapid, sustained thermal control and were effective in preventing hypothermia in preterm newborns.

Doulas in the Operating Room: An Innovative Approach to Supporting Skin-to-Skin Care During Cesarean Birth

INTRODUCTION

Skin-to-skin care (SSC) immediately after birth is recommended for all women and their newborns. Barriers to SSC after cesarean birth lead to delays in initiation of this practice. The purpose of this quality improvement project was to implement an innovative approach with volunteer doulas to support initiation of SSC after cesarean for all clients.

PROCESS

Volunteer doulas in a well-established hospital-based program within an academic health center were trained to provide care during scheduled cesarean births in the operating and recovery rooms. Data on rate and time of SSC and client and nurse satisfaction were collected for a 12-week period.

OUTCOMES

Sixty-six women received doula-supported care in the operating room. All medically stable woman-newborn couplets with complete data (N = 58) initiated SSC in the operating room and were included in the data analysis. Forty-eight women completed a feedback survey after birth. Scores indicated that clients agreed or strongly agreed that the doula was an important part of the birth experience. Feedback from labor and delivery nurses indicated highly positive attitudes about the importance of SSC and the presence of volunteer doulas. All nurses surveyed who had participated in doula care (n = 20) agreed or strongly agreed that they were satisfied with the doulas and that the doulas were prepared for this role.

DISCUSSION

This project demonstrates that volunteer doulas can be prepared to provide supportive care to clients during and immediately after cesarean birth. Doulas can play an integral role in supporting the initiation of SSC after cesarean birth and are perceived as an important member of the maternity health care team by clients and nurses.

Observation study showed that the continuity of skin-to-skin contact with low-birthweight infants in Uganda was suboptimal

AIM

Kangaroo mother care (KMC) is a safe and effective method of reducing neonatal mortality in resource-limited settings, but there has been a lack of data on the duration of skin-to-skin contact (SSC) in busy, low-resource newborn units. Previous studies of intermittent KMC suggest the duration of SSC ranged from 10 minutes to 17 hours per day.

METHODS

This was an observational study of newborn infants born weighing less than 2000 g, which collected quantitative data on SSC over the first week after birth. The study took place in July 2016 in the newborn unit of a low-resource facility in Uganda.

RESULTS

The mean daily duration of SSC over the first week after birth was three hours. This differed significantly from the World Health Organization recommendation of at least 20 hours of SSC per day. SSC was provided by mothers most of the time (73.5%), but other family members also took part, especially on the day of birth.

CONCLUSION

Our study found a disappointingly low daily duration of SSC in this Ugandan newborn unit. However, advocacy and community education of SSC may help to decrease the stigma of KMC, improve overall acceptance and reduce the age at SSC initiation.

Kangaroo mother care for clinically unstable neonates weighing ≤2000 g: Is it feasible at a hospital in Uganda?

BACKGROUND

Kangaroo mother care (KMC) for stable neonates ≤2000 g (g) is associated with decreased mortality, sepsis, hypothermia, and length of stay compared to conventional care. The World Health Organization states that KMC "should be initiated… as soon as newborns are clinically stable" [12]. However, the majority of deaths occur in unstable neonates. We aimed to determine the proportion of admitted neonates meeting proposed instability criteria, assess the feasibility of providing KMC to unstable neonates, and evaluate the acceptability of this intervention to parents and providers at Jinja Regional Referral Hospital in Uganda.

METHODS

This was a mixed-methods study. We recorded data including birthweight, chronological age, and treatments administered from medical charts, and calculated the percentage of clinically unstable neonates, defined as the need for ≥2 medical therapies in the first 48 hours of admission. We enrolled a sample of neonates meeting pre-defined instability criteria. Mothers were counselled to provide KMC as close to continuously as possible. We calculated the median duration of KMC per episode and per day. To explore acceptability, we conducted semi-structured interviews with parents and newborn unit care providers, and analysed data using the thematic content approach.

FINDINGS

We included 254 neonates in the audit, 10 neonates in the feasibility sub-study, and 20 participants in the acceptability sub-study. Instability criteria were easily implementable, identifying 89% of neonates as unstable in the audit. The median duration of individual KMC episodes ranged from 115 to 134 minutes. The median daily duration ranged from 4.5 to 9.7 hours. Seventy-five percent of interviewees felt KMC could be used in neonates concurrently receiving other medical therapies. Barriers included lack of resources (beds/space, monitoring devices), privacy issues, inadequate education, and difficulties motivating mothers to devote time to KMC. Recommendations included staff/peer counselling, resources, family support, and community outreach.

CONCLUSIONS

There remains a need for an evidence-based approach to consistently define stability criteria for KMC to improve care. We found that KMC for unstable neonates weighing ≤2000g was feasible and acceptable at Jinja Hospital in Uganda. Randomised controlled trials are needed to demonstrate the effect of KMC on survival among unstable neonates in low-resource settings.

Circulatory Insufficiency and Hypotension Related to the Ductus Arteriosus in Neonates

The biological role of the ductus arteriosus (DA) in neonates varies from an innocent bystander role during normal postnatal transition, to a supportive role when there is compromise to either systemic or pulmonary blood flow, to a pathological state in the presence of hemodynamically significant systemic to pulmonary shunts, as occurs in low birth weight infants. Among a wide array of clinical manifestations arising due to the ductal entity, systemic circulatory insufficiency and hypotension are of significant concern as they are particularly challenging to manage. An understanding of the physiologic interplay between the DA and the circulatory system is the key to developing appropriate targeted therapeutic strategies. In this review, we discuss the relationship of systemic hypotension to the DA, emphasizing the importance of critical thinking and a precise individual approach to intensive care support. We particularly focus on the variable states of hypotension arising directly due to a hemodynamically significant DA or seen in the period following successful surgical ligation. In addition, we explore the mechanistic contributions of the ductus to circulatory insufficiency that may manifest during the transitional period, states of maladapted transition (such as acute pulmonary hypertension of the newborn), and congenital heart disease (both ductal dependent and non-ductal dependent lesions). Understanding the dynamic modulator role of the ductus according to the ambient physiology enables a more precise approach to management. We review the pathophysiology, clinical manifestations, diagnosis, monitoring, and therapeutic intervention for the spectrum of DA-related circulatory compromise.

Interventions to prevent hypothermia at birth in preterm and/or low birth weight infants

BACKGROUND

Newborn admission temperature is a strong predictor of outcomes across all gestations. Hypothermia immediately after birth remains a worldwide issue and, if prolonged, is associated with harm. Keeping preterm infants warm is difficult even when recommended routine thermal care guidelines are followed in the delivery room.

OBJECTIVES

To assess the efficacy and safety of interventions designed for prevention of hypothermia in preterm and/or low birth weight infants applied within 10 minutes after birth in the delivery room, compared with routine thermal care or any other single/combination of intervention(s) also designed for prevention of hypothermia in preterm and/or low birth weight infants applied within 10 minutes after birth in the delivery room.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 5), MEDLINE via PubMed (1966 to 30 June 2016), Embase (1980 to 30 June 2016), and CINAHL (1982 to 30 June 2016). We also searched clinical trials databases, conference proceedings, and reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Trials using randomised or quasi-randomised allocations to test interventions designed to prevent hypothermia (apart from 'routine' thermal care) applied within 10 minutes after birth in the delivery room for infants at < 37 weeks' gestation and/or birth weight ≤ 2500 grams.

DATA COLLECTION AND ANALYSIS

We used Cochrane Neonatal methods when performing data collection and analysis.

MAIN RESULTS

Twenty-five studies across 15 comparison groups met the inclusion criteria, categorised as: barriers to heat loss (18 studies); external heat sources (three studies); and combinations of interventions (four studies).Barriers to heat loss Plastic wrap or bag versus routine carePlastic wraps improved core body temperature on admission to the neonatal intensive care unit (NICU) or up to two hours after birth (mean difference (MD) 0.58°C, 95% confidence interval (CI) 0.50 to 0.66; 13 studies; 1633 infants), and fewer infants had hypothermia on admission to the NICU or up to two hours after birth (typical risk ratio (RR) 0.67, 95% CI 0.62 to 0.72; typical risk reduction (RD) -0.25, 95% CI -0.29 to -0.20; number needed to treat for an additional beneficial outcome (NNTB) 4, 95% CI 4 to 5; 10 studies; 1417 infants). Risk of hyperthermia on admission to the NICU or up to two hours after birth was increased in infants in the wrapped group (typical RR 3.91, 95% CI 2.05 to 7.44; typical RD 0.04, 95% CI 0.02 to 0.06; number needed to treat for an additional harmful outcome (NNTH) 25, 95% CI 17 to 50; 12 studies; 1523 infants), but overall, fewer infants receiving plastic wrap were outside the normothermic range (typical RR 0.75, 95% CI 0.69 to 0.81; typical RD -0.20, 95% CI -0.26 to -0.15; NNTH 5, 95% CI 4 to 7; five studies; 1048 infants).Evidence was insufficient to suggest that plastic wraps or bags significantly reduce risk of death during hospital stay or other major morbidities, with the exception of reducing risk of pulmonary haemorrhage.Evidence of practices regarding permutations on this general approach is still emerging and has been based on the findings of only one or two small studies.External heat sourcesEvidence is emerging on the efficacy of external heat sources, including skin-to-skin care (SSC) versus routine care (one study; 31 infants) and thermal mattress versus routine care (two studies; 126 infants).SSC was shown to be effective in reducing risk of hypothermia when compared with conventional incubator care for infants with birth weight ≥ 1200 and ≤ 2199 grams (RR 0.09, 95% CI 0.01 to 0.64; RD -0.56, 95% CI -0.84 to -0.27; NNTB 2, 95% CI 1 to 4). Thermal (transwarmer) mattress significantly kept infants ≤ 1500 grams warmer (MD 0.65°C, 95% CI 0.36 to 0.94) and reduced the incidence of hypothermia on admission to the NICU, with no significant difference in hyperthermia risk.Combinations of interventionsTwo studies (77 infants) compared thermal mattresses versus plastic wraps or bags for infants at ≤ 28 weeks' gestation. Investigators reported no significant differences in core body temperature nor in the incidence of hypothermia, hyperthermia, or core body temperature outside the normothermic range on admission to the NICU.Two additional studies (119 infants) compared plastic bags and thermal mattresses versus plastic bags alone for infants at < 31 weeks' gestation. Meta-analysis of these two studies showed improvement in core body temperature on admission to the NICU or up to two hours after birth, but an increase in hyperthermia. Data show no significant difference in the risk of having a core body temperature outside the normothermic range on admission to the NICU nor in the risk of other reported morbidities.

AUTHORS' CONCLUSIONS

Evidence of moderate quality shows that use of plastic wraps or bags compared with routine care led to higher temperatures on admission to NICUs with less hypothermia, particularly for extremely preterm infants. Thermal mattresses and SSC also reduced hypothermia risk when compared with routine care, but findings are based on two or fewer small studies. Caution must be taken to avoid iatrogenic hyperthermia, particularly when multiple interventions are used simultaneously. Limited evidence suggests benefit and no evidence of harm for most short-term morbidity outcomes known to be associated with hypothermia, including major brain injury, bronchopulmonary dysplasia, retinopathy of prematurity, necrotising enterocolitis, and nosocomial infection. Many observational studies have shown increased mortality among preterm hypothermic infants compared with those who maintain normothermia, yet evidence is insufficient to suggest that these interventions reduce risk of in-hospital mortality across all comparison groups. Hypothermia may be a marker for illness and poorer outcomes by association rather than by causality. Limitations of this review include small numbers of identified studies; small sample sizes; and variations in methods and definitions used for hypothermia, hyperthermia, normothermia, routine care, and morbidity, along with lack of power to detect effects on morbidity and mortality across most comparison groups. Future studies should: be adequately powered to detect rarer outcomes; apply standardised morbidity definitions; focus on longer-term outcomes, particularly neurodevelopmental outcomes.

The Positive Association Between Duration of Skin-to-Skin Contact and Blood Glucose Level in Full-Term Infants

The aim of this study was to evaluate the contribution of the duration of skin-to-skin contact (SSC) on blood glucose levels at 2 hours after birth in healthy full-term infants. This observational study was done at one of the baby-friendly hospitals located in Aichi, Japan in 2009. Sixty newborn infants who were born vaginally from uncomplicated pregnancies were participated. All infants were held SSC within 5 minutes. All data regarding neonatal information, blood glucose levels at 2 hours of age, and maternal information were obtained from their medical history. Multiple linear regression analysis was performed to identify the independent contribution of the duration of SSC. The mean duration of SSC was 59.6 ± 13.6 minutes (range: 11.0-97.0 minutes) and the infant blood glucose level was 53.1 ± 9.5 (range: 30.0-80.0 mg/dL) mg/dL. The duration of SSC (β [95% confidence interval] = .282 [range: 0.037-0.357], standardized β = .282, P < .017) was significantly and positively associated with infant blood glucose levels independent of gestational age, birth weight, sex, length of second-stage labor, and mode of delivery. Thus, the longer early SSC was associated with higher blood glucose level at 2 hours of age in healthy full-term infants.

An implementation algorithm to improve skin-to-skin practice in the first hour after birth

Evidence supporting the practice of skin‐to‐skin contact and breastfeeding soon after birth points to physiologic, social, and psychological benefits for both mother and baby. The 2009 revision of Step 4 of the WHO/UNICEF “Ten Steps to Successful Breastfeeding” elaborated on the practice of skin‐to‐skin contact between the mother and her newly born baby indicating that the practice should be “immediate” and “without separation” unless documented medically justifiable reasons for delayed contact or interruption exist. While in immediate, continuous, uninterrupted skin‐to‐skin contact with mother in the first hour after birth, babies progress through 9 instinctive, complex, distinct, and observable stages including self‐attachment and suckling. However, the most recent Cochrane review of early skin‐to‐skin contact cites inconsistencies in the practice; the authors found “inadequate evidence with respect to details … such as timing of initiation and dose.” This paper introduces a novel algorithm to analyse the practice of skin to skin in the first hour using two data sets and suggests opportunities for practice improvement. The algorithm considers the mother's Robson criteria, skin‐to‐skin experience, and Widström's 9 Stages. Using data from vaginal births in Japan and caesarean births in Australia, the algorithm utilizes data in a new way to highlight challenges to best practice. The use of a tool to analyse the implementation of skin‐to‐skin care in the first hour after birth illuminates the successes, barriers, and opportunities for improvement to achieving the standard of care for babies. Future application should involve more diverse facilities and Robson's classifications.