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Swieter E, Gross JM, Stephen J, Watterberg K, Maxwell JR. Pilot study shows skin-to-skin care with parents improves heart rate variability in preterm infants in the neonatal intensive care unit. Front Pediatr 2023; 11:1269405. [PMID: 37790693 PMCID: PMC10544889 DOI: 10.3389/fped.2023.1269405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 09/01/2023] [Indexed: 10/05/2023] Open
Abstract
Background Skin-to-skin care in the newborn intensive care unit typically lasts for short periods of time and enhances breastfeeding, attachment, and parental self-esteem. Heart rate variability (HRV) increases with gestational age and is a measure of maturation of parasympathetic vs. sympathetic autonomic nervous system activity. HRV measurements may be useful in capturing changes in autonomic regulation in response to skin-to-skin care. Objective To analyze the effects of skin-to-skin care on HRV in preterm infants receiving respiratory support. We hypothesized that skin-to-skin care would result in a more mature pattern of parasympathetic activity. Methods In this prospective crossover study, infants <30 weeks' gestation and 1-6 weeks postnatal age had HRV recorded for 30 min before, during, and after skin-to-skin care sessions. HRV characteristics analyzed included the standard deviation of the normal-to-normal interval (SDNN), the root mean squared of successive differences of normal-to-normal intervals (RMSSD), and the standard deviation of decelerations (SDDec). Results 10 infants between 25 5/7-29 6/7 weeks gestational age and 7-41 days postnatal age completed 22 sessions while receiving respiratory support (positive pressure ventilation or nasal cannula oxygen). Two measures of HRV (SDNN and RMSSD) were significantly decreased by the end of the skin-to-skin sessions, compared to pre-session values. SDNN decreased from a median of 10.44 ms before the session to 6.70 ms after being placed back in bed (p < 0.05), with RMSSD decreasing from a median of 6.80 ms before the session to 4.32 ms while being held at the end of 30 min (p < 0.05). Discussion Skin-to-skin care with a parent resulted in a more mature autonomic nervous system pattern in preterm infants receiving respiratory support, suggesting physiologic benefit for the infant. No adverse events were seen during any session.
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Affiliation(s)
- Erin Swieter
- Department of Pediatrics, University of New Mexico, Albuquerque, NM, United States
| | - Jessica M. Gross
- Clinical and Translational Science Center, University of New Mexico, Albuquerque, NM, United States
| | - Julia Stephen
- The Mind Research Network a Division of Lovelace Biomedical Research Institute, Albuquerque, NM, United States
| | - Kristi Watterberg
- Department of Pediatrics, University of New Mexico, Albuquerque, NM, United States
| | - Jessie R. Maxwell
- Department of Pediatrics, University of New Mexico, Albuquerque, NM, United States
- Department of Neurosciences, University of New Mexico, Albuquerque, NM, United States
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Kokkinaki T, Markodimitraki M, Giannakakis G, Anastasiou I, Hatzidaki E. Comparing Full and Pre-Term Neonates' Heart Rate Variability in Rest Condition and during Spontaneous Interactions with Their Parents at Home. Healthcare (Basel) 2023; 11:healthcare11050672. [PMID: 36900677 PMCID: PMC10000654 DOI: 10.3390/healthcare11050672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 02/18/2023] [Accepted: 02/22/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Preterm neonates show decreased HRV compared to those at full-term. We compared HRV metrics between preterm and full-term neonates in transfer periods from neonate rest state to neonate-parent interaction, and vice versa. METHODS Short-term recordings of the HRV parameters (time and frequency-domain indices and non-linear measurements) of 28 premature healthy neonates were compared with the metrics of 18 full-term neonates. HRV recordings were performed at home at term-equivalent age and HRV metrics were compared between the following transfer periods: from first rest state of the neonate (TI1) to a period in which the neonate interacted with the first parent (TI2), from TI2 to a second neonate rest state (TI3), and from TI3 to a period of neonate interaction with the second parent (TI4). RESULTS For the whole HRV recording period, PNN50, NN50 and HF (%) was lower for preterm neonates compared to full-terms. These findings support the reduced parasympathetic activity of preterm compared to full-term neonates. The results of comparisons between transfer period simply a common coactivation of SNS and PNS systems for both full and pre-term neonates. CONCLUSIONS Spontaneous interaction with the parent may reinforce both full and pre-term neonates' ANS maturation.
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Affiliation(s)
- Theano Kokkinaki
- Child Development and Education Unit, Laboratory of Applied Psychology, Department of Psychology, University of Crete, 74150 Rethymnon, Greece
- Correspondence: ; Tel.: +30-28310-77536
| | | | - Giorgos Giannakakis
- Institute of Computer Science, Foundation for Research and Technology, 70013 Heraklion, Greece
| | - Ioannis Anastasiou
- Cardiology Department, University Hospital of Heraklion, University of Crete, 71500 Heraklion, Greece
| | - Eleftheria Hatzidaki
- Department of Neonatology/Neonatal Intensive Care Unit, University Hospital of Heraklion, School of Medicine, University of Crete, 71500 Heraklion, Greece
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Fernandes O, Marra da Silva R, Rego Ramos L, Gama TM, Lobo I, Guerra Leal Souza G, Arruda Sanchez T. The impact of a violent community on mental health and the benefits of a sport program for social development. JOURNAL OF COMMUNITY PSYCHOLOGY 2023; 51:51-66. [PMID: 35583853 DOI: 10.1002/jcop.22877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/28/2022] [Accepted: 04/25/2022] [Indexed: 06/15/2023]
Abstract
The aim of the present study was to evaluate the impact of a violent environment on mental health and the impact of a sport for social development (SSD) program on quality of life, mental distress symptoms, and heart rate variability (HRV). HRV and psychometric data were measured from 20 men professional athletes assisted by the SSD and 20 men living in the same violent community. The comparison of groups revealed greater sympathetic parameters of HRV, positive affect, and quality of life in the SSD group. Multiple regression analysis showed that the quality of life in the SSD group was positively predicted by positive affect, while in the control group the quality of life was negatively predicted by their history of traumatic events. Both groups reported high levels of exposure to traumatic events and posttraumatic stress symptoms. However, this study demonstrates the benefits of SSD programs in mental health.
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Affiliation(s)
- Orlando Fernandes
- Laboratório de Neuroimagem e Psicofisiologia, Departamento de Radiologia, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ruy Marra da Silva
- Laboratório de Neuroimagem e Psicofisiologia, Departamento de Radiologia, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
- Programa de Pós-graduação em Cardiologia, Instituto do Coração Edson Saad, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Lucas Rego Ramos
- Laboratório de Neuroimagem e Psicofisiologia, Departamento de Radiologia, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Tamires M Gama
- Laboratório de Neuroimagem e Psicofisiologia, Departamento de Radiologia, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Isabela Lobo
- Grupo de Psicobiologia/Laboratório Integrado de Morfologia, Instituto de Biodiversidade e Sustentabilidade/NUPEM, Universidade Federal do Rio de Janeiro, Macaé, Rio de Janeiro, Brazil
| | - Gabriela Guerra Leal Souza
- Laboratório de Psicofisiologia, Departamento de Ciências Biológicas, Universidade Federal de Ouro Preto, Ouro Preto, Minas Gerais, Brazil
| | - Tiago Arruda Sanchez
- Laboratório de Neuroimagem e Psicofisiologia, Departamento de Radiologia, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
- Programa de Pós-graduação em Cardiologia, Instituto do Coração Edson Saad, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
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Characterizing the effect of demographics, cardiorespiratory factors, and inter-subject variation on maternal heart rate variability in pregnancy with statistical modeling: a retrospective observational analysis. Sci Rep 2022; 12:19305. [PMID: 36369252 PMCID: PMC9651120 DOI: 10.1038/s41598-022-21792-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 10/04/2022] [Indexed: 11/13/2022] Open
Abstract
Pregnancy complications are associated with insufficient adaptation of the maternal autonomic nervous system to the physiological demands of pregnancy. Consequently, assessing maternal heart rate variability (mHRV)-which reflects autonomic regulation-is a promising tool for detecting early deterioration in maternal health. However, before mHRV can be used to screen for complications, an understanding of the factors influencing mHRV during healthy pregnancy is needed. In this retrospective observational study, we develop regression models to unravel the effects of maternal demographics (age, body mass index (BMI), gestational age (GA), and parity), cardiorespiratory factors (heart rate and breathing rate), and inter-subject variation on mHRV. We develop these models using two datasets which are comprised of, respectively, single measurements in 290 healthy pregnant women and repeated measurements (median = 8) in 29 women with healthy pregnancies. Our most consequential finding is that between one-third and two-thirds of the variation in mHRV can be attributed to inter-subject variability. Additionally, median heart rate dominantly affects mHRV (p < 0.001), while BMI and parity have no effect. Moreover, we found that median breathing rate, age, and GA all impact mHRV (p < 0.05). These results suggest that personalized, long-term monitoring would be necessary for using mHRV for obstetric screening.
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Vismara L, Gianmaria Tarantino A, Bergna A, Bianchi G, Bragalini C, Billò E, Dal Farra F, Buffone F, Agosti M. Correlation between diminished vagal tone and somatic dysfunction severity in very and extremely low birth weight preterm infants assessed with frequency spectrum heart rate variability and salivary cortisol. Medicine (Baltimore) 2022; 101:e30565. [PMID: 36197184 PMCID: PMC9509086 DOI: 10.1097/md.0000000000030565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Osteopathic manipulative treatment (OMT) is evolving in the neonatal intensive care unit (NICU) setting. Studies showed its efficacy in length of stay and hospitalization costs reduction. Moreover, it was suggested that OMT has a modulatory effect on the preterm infants' autonomic nervous system (ANS), influencing saturation and heart rate. Even if OMT is based on the palpatory examination of the somatic dysfunctions (SD), there are controversies about its identification and clinical relevance. The objective of this study was to evaluate the inter-rater reliability, clinical characteristics, and functional correlation of the SD Grade score with the heart rate variability (HRV) and the salivary cortisol (sCor) using a multivariate linear model approach. To evaluate those features, we implemented an ad hoc SD examination for preterm infants that was performed by 2 trained osteopaths. It was based on the new variability model of SD that includes an SD Grade assessment procedure. The ANS features were assessed by frequency parameters of HRV studying high frequency (HF), low frequency (LF), and HF/LF, whereas sCor was tested with a radioimmunoassay. The ANS assessment was standardized and performed before SD testing. Sixty-nine premature infants were eligible. SD Grade showed excellent concordance between the blinded raters. Using SD Grade as a grouping variable, the infants presented differences in GA, Apgar, pathological findings, length of stay, and ventilatory assistance. In our multivariate model, HF, LF, and LF/HF resulted linearly correlated with SD Grade. Instead, sCor presented a linear correlation with 5' Apgar and respiratory distress syndrome but not with SD Grade. SD Grade was in line with the natural history of the underdevelopment due to prematurity. Our models indicate that the cardiac vagal tone is linearly related with SD Grade. This finding may improve the multidisciplinary decision making inside NICU and the management of modifiable factors, like SD, for cardiac vagal tone regulation.
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Affiliation(s)
- Luca Vismara
- Division of Neurology and Neurorehabilitation, IRCCS Istituto Auxologico Italiano, Piancavallo-Verbania, Italy
- Division of Paediatric, Manima Non-Profit Organization Social Assistance and Healthcare, Milan, Italy
- Department of Research, SOMA – Istituto Osteopatia Milano, Milan, Italy
- *Correspondence: Luca Vismara, Division of Neurology and Neurorehabilitation, IRCCS IstitutoAuxologico Italiano, Piancavallo-Verbania, Italy (e-mail: )
| | - Andrea Gianmaria Tarantino
- Department of Research, SOMA – Istituto Osteopatia Milano, Milan, Italy
- Woman and Child Department, Varese Hospital, Insubria University, via Ravasi 2 21100 Varese, Italy
| | - Andrea Bergna
- Woman and Child Department, Varese Hospital, Insubria University, via Ravasi 2 21100 Varese, Italy
| | - Giuliana Bianchi
- PPCR, Harvard T.H. Chan School of Public Health - ECPE, Boston, MA, USA
| | | | - Elisa Billò
- Department of Research, SOMA – Istituto Osteopatia Milano, Milan, Italy
| | - Fulvio Dal Farra
- Woman and Child Department, Varese Hospital, Insubria University, via Ravasi 2 21100 Varese, Italy
| | - Francesca Buffone
- Department of Research, SOMA – Istituto Osteopatia Milano, Milan, Italy
- Woman and Child Department, Varese Hospital, Insubria University, via Ravasi 2 21100 Varese, Italy
| | - Massimo Agosti
- PPCR, Harvard T.H. Chan School of Public Health - ECPE, Boston, MA, USA
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Israeli-Mendlovic H, Mendlovic J, Zuk L, Katz-Leurer M. High frequency band limits in spectral analysis of heart rate variability in preterm infants. J Perinat Med 2022; 50:351-355. [PMID: 34881542 DOI: 10.1515/jpm-2021-0299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 11/14/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The current study aims to assess different high-frequency (HF) band power calculations based on different frequency bandwidth values, and compare them with the time domain the root mean square of successive RR differences (RMSSD) value in preterm infants. METHODS At week 32, electrocardiogram (ECG) and breathing rate (BR) were recorded for 24 h on 30 preterm infants born between 28 and 32 weeks. The recording held in the neonatal intensive care unit without any interruption of routine. RESULTS The median 24 h BR was 40-78 breaths per minute. The RMSSD was highly and positively correlated with frequency bands that were based on each preterms BR range, or on a constant frequency with band limits of 0.4-2 Hz. CONCLUSIONS At week 32, HF band Hz limits should be calculated based on each child's breathing rate, generally between 0.4 and 2 Hz.
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Affiliation(s)
- Hadas Israeli-Mendlovic
- Physical Therapy Department, School of Health Professions, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Luba Zuk
- Physical Therapy Department, School of Health Professions, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Katz-Leurer
- Physical Therapy Department, School of Health Professions, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Latremouille S, Lam J, Shalish W, Sant'Anna G. Neonatal heart rate variability: a contemporary scoping review of analysis methods and clinical applications. BMJ Open 2021; 11:e055209. [PMID: 34933863 PMCID: PMC8710426 DOI: 10.1136/bmjopen-2021-055209] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Samantha Latremouille
- Division of Experimental Medicine, McGill University Health Centre, Montreal, Québec, Canada
| | - Justin Lam
- Medicine, Griffith University, Nathan, Queensland, Australia
| | - Wissam Shalish
- Division of Neonatology, McGill University Health Center, Montreal, Québec, Canada
| | - Guilherme Sant'Anna
- Division of Neonatology, McGill University Health Center, Montreal, Québec, Canada
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Leon C, Cabon S, Patural H, Gascoin G, Flamant C, Roue JM, Favrais G, Beuchee A, Pladys P, Carrault G. Evaluation of maturation in preterm infants through an ensemble machine learning algorithm using physiological signals. IEEE J Biomed Health Inform 2021; 26:400-410. [PMID: 34185652 DOI: 10.1109/jbhi.2021.3093096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
This study was designed to test if heart rate variability (HRV) data from preterm and full-term infants could be used to estimate their functional maturational age (FMA), using a machine learning model. We propose that the FMA, and its deviation from the postmenstrual age (PMA) of the infants could inform physicians about the progress of the maturation of the infants. The HRV data was acquired from 50 healthy infants, born between 25 and 41 weeks of gestational age, who did not present any signs of abnormal maturation relative to their age group during the period of observation. The HRV features were used as input for a machine learning model that uses filtering and genetic algorithms for feature selection, and an ensemble machine learning (EML) algorithm, which combines linear and random forest regressions, to produce as output a FMA. Using HRV data, the FMA had a mean absolute error of 0.93 weeks, 95% CI [0.78, 1.08], compared to the PMA. These results demonstrate that HRV features of newborn infants can be used by an EML model to estimate their FMA. This method was also generalized using respiration rate variability (RRV) and bradycardia data, obtaining similar results. The FMA, predicted either by HRV, RRV or bradycardia, and its deviation from the true PMA of the infants, could be used as a surrogate measure of the maturational age of the infants, which could potentially be monitored non-invasively and in real-time in the setting of neonatal intensive care units.
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Chiera M, Cerritelli F, Casini A, Barsotti N, Boschiero D, Cavigioli F, Corti CG, Manzotti A. Heart Rate Variability in the Perinatal Period: A Critical and Conceptual Review. Front Neurosci 2020; 14:561186. [PMID: 33071738 PMCID: PMC7544983 DOI: 10.3389/fnins.2020.561186] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 08/28/2020] [Indexed: 12/18/2022] Open
Abstract
Neonatal intensive care units (NICUs) greatly expand the use of technology. There is a need to accurately diagnose discomfort, pain, and complications, such as sepsis, mainly before they occur. While specific treatments are possible, they are often time-consuming, invasive, or painful, with detrimental effects for the development of the infant. In the last 40 years, heart rate variability (HRV) has emerged as a non-invasive measurement to monitor newborns and infants, but it still is underused. Hence, the present paper aims to review the utility of HRV in neonatology and the instruments available to assess it, showing how HRV could be an innovative tool in the years to come. When continuously monitored, HRV could help assess the baby’s overall wellbeing and neurological development to detect stress-/pain-related behaviors or pathological conditions, such as respiratory distress syndrome and hyperbilirubinemia, to address when to perform procedures to reduce the baby’s stress/pain and interventions, such as therapeutic hypothermia, and to avoid severe complications, such as sepsis and necrotizing enterocolitis, thus reducing mortality. Based on literature and previous experiences, the first step to efficiently introduce HRV in the NICUs could consist in a monitoring system that uses photoplethysmography, which is low-cost and non-invasive, and displays one or a few metrics with good clinical utility. However, to fully harness HRV clinical potential and to greatly improve neonatal care, the monitoring systems will have to rely on modern bioinformatics (machine learning and artificial intelligence algorithms), which could easily integrate infant’s HRV metrics, vital signs, and especially past history, thus elaborating models capable to efficiently monitor and predict the infant’s clinical conditions. For this reason, hospitals and institutions will have to establish tight collaborations between the obstetric, neonatal, and pediatric departments: this way, healthcare would truly improve in every stage of the perinatal period (from conception to the first years of life), since information about patients’ health would flow freely among different professionals, and high-quality research could be performed integrating the data recorded in those departments.
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Affiliation(s)
- Marco Chiera
- Research and Assistance for Infants to Support Experience Lab, Foundation Center for Osteopathic Medicine Collaboration, Pescara, Italy.,Research Commission on Manual Therapies and Mind-Body Disciplines, Societ Italiana di Psico Neuro Endocrino Immunologia, Rome, Italy
| | - Francesco Cerritelli
- Research and Assistance for Infants to Support Experience Lab, Foundation Center for Osteopathic Medicine Collaboration, Pescara, Italy
| | - Alessandro Casini
- Research and Assistance for Infants to Support Experience Lab, Foundation Center for Osteopathic Medicine Collaboration, Pescara, Italy
| | - Nicola Barsotti
- Research and Assistance for Infants to Support Experience Lab, Foundation Center for Osteopathic Medicine Collaboration, Pescara, Italy.,Research Commission on Manual Therapies and Mind-Body Disciplines, Societ Italiana di Psico Neuro Endocrino Immunologia, Rome, Italy
| | | | - Francesco Cavigioli
- Neonatal Intensive Care Unit, "V. Buzzi" Children's Hospital, Azienda Socio Sanitaria Territoriale Fatebenefratelli-Sacco, Milan, Italy
| | - Carla G Corti
- Pediatric Cardiology Unit-Pediatric Department, Azienda Socio Sanitaria Territoriale Fatebenefratelli-Sacco, Milan, Italy
| | - Andrea Manzotti
- Research and Assistance for Infants to Support Experience Lab, Foundation Center for Osteopathic Medicine Collaboration, Pescara, Italy.,Neonatal Intensive Care Unit, "V. Buzzi" Children's Hospital, Azienda Socio Sanitaria Territoriale Fatebenefratelli-Sacco, Milan, Italy.,Research Department, SOMA, Istituto Osteopatia Milano, Milan, Italy
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