Skin-to-skin (kangaroo) care, respiratory control, and thermoregulation

Kangaroo mother care improves cardiorespiratory physiology in preterm infants: an observational study

OBJECTIVES

To evaluate whether kangaroo mother care (KMC) in preterm infants on non-invasive respiratory support improves indices of cardiorespiratory wellbeing.

STUDY DESIGN

Prospective quasi-experimental observational study.

SETTING

Tertiary perinatal neonatal unit.

PATIENTS

50 very preterm infants being managed with nasal continuous positive airway pressure.

INTERVENTIONS

Continuous high-resolution preductal pulse-oximetry recordings using Masimo Radical-7 oximeter for 1 hour (incubator care) followed by 1 hour during KMC performed on the same day.

MAIN OUTCOME MEASURES

Measures of cardiorespiratory stability (dips in oxygen saturations (SpO2)) of ≥5% less than baseline, % time spent with oxygen saturations <90%, SpO2 variability and heart rate fluctuation and incidence of bradycardias.

RESULTS

The gestational age and birth weight of the cohort were 28.4±2.1 weeks and 1137±301 g, respectively. Dips in SpO2 of ≥5% less than baseline were significantly fewer with KMC, median (IQR) 24 (12 to 42) vs 13 (3 to 25), p=0.001. SpO2 variability (Delta 12 s and 2 s), (1.24±0.6 vs 0.9±0.4, p=0.005 and 4.1±1.7 vs 2.8±1.2, p<0.0001) and rapid resaturation and desaturation indices were significantly lower during KMC, compared with incubator care. Percentage time spent in oxygen saturations <90% was less with KMC (7.5% vs 2.7%, p=0.04). Mean heart rate was comparable although fluctuations in heart rate (rise by >8 bpm) were lower with KMC (43±22 vs 33±20, p=0.03). Seven (14%) infants had bradycardias during incubator care and none during KMC, p=0.012.

CONCLUSIONS

KMC improves cardiorespiratory stability in ventilated preterm infants. Regular KMC has the potential to improve clinical outcomes in this vulnerable cohort.

Monitoring lung and cerebral oxygenation using near-infrared spectroscopy in preterm infants during kangaroo mother care

Lung function has never been assessed during kangaroo mother care (KMC) in preterm infants. We measured lung (rSO2L) and cerebral (rSO2C) oxygenation by near-infrared spectroscopy (NIRS) in infants born at less than 32 weeks of gestation or weighing ≤ 1500 g during KMC. rSO2L, rSO2C, and pulmonary (FOEL) and cerebral (FOEC) tissue oxygen extraction fraction were measured in 20 preterm infants before, during, and after a 2-h period of KMC at a mean postnatal age of 36 ± 21 days of life. We found that rSO2L, rSO2C, FOEL, and FOEC did not change in our patients. After 120 min of KMC, rSO2L was lower (71.3 ± 1.4 vs. 76.7 ± 4.6%; P = 0.012) in infants with BPD (n = 6; 30%) than in infants without BPD (n = 14 = 60%), while FOEL was higher (0.26 ± 0.02 vs. 0.20 ± 0.05; P = 0.012).Conclusion: Cerebral and lung oxygenation did not change in preterm infants during KMC. A transient decrease in lung oxygenation was offset by the increase in oxygen extraction, but these changes were clinically insignificant. These results confirm the safety of KMC in preterm infants who are in stable clinical conditions. What is Known • Kangaroo mother care (KMC) is widely used to improve the care of preterm newborns since it improves their outcome. • KMC is safe as patients' vital parameters, are not negatively affected, but lung function has never been directly assessed. What is New • Cerebral and lung oxygenation measured by near-infrared spectroscopy did not change during KMC. • A transient decrease in lung oxygenation compensated for by the increase in oxygen extraction occurred only in infants with BPD, but these changes were clinically insignificant.

Too hot to thrive: a qualitative inquiry of community perspectives on the effect of high ambient temperature on postpartum women and neonates in Kilifi, Kenya

OBJECTIVE

To understand community perspectives on the effects of high ambient temperature on the health and wellbeing of neonates, and impacts on post-partum women and infant care in Kilifi.

DESIGN

Qualitative study using key informant interviews, in-depth interviews and focus group discussions with pregnant and postpartum women (n = 22), mothers-in-law (n = 19), male spouses (n = 20), community health volunteers (CHVs) (n = 22) and stakeholders from health and government ministries (n = 16).

SETTINGS

We conducted our research in Kilifi County in Kenya's Coast Province. The area is largely rural and during summer, air temperatures can reach 37˚C and rarely go below 23˚C.

DATA ANALYSIS

Data were analyzed in NVivo 12, using both inductive and deductive approaches.

RESULTS

High ambient temperature is perceived by community members to have direct and indirect health pathways in pregnancy and postpartum periods, including on the neonates. The direct impacts include injuries on the neonate's skin and in the mouth, leading to discomfort and affecting breastfeeding and sleeping. Participants described babies as "having no peace". Heat effects were perceived to be amplified by indoor air pollution and heat from indoor cooking fires. Community members believed that exclusive breastfeeding was not practical in conditions of extreme heat because it lowered breast milk production, which was, in turn, linked to a low scarcity of food and time spend by mothers away from their neonates performing household chores. Kangaroo Mother Care (KMC) was also negatively affected. Participants reported that postpartum women took longer to heal in the heat, were exhausted most of the time and tended not to attend postnatal care.

CONCLUSIONS

High ambient temperatures affect postpartum women and their neonates through direct and indirect pathways. Discomfort makes it difficult for the mother to care for the baby. Multi-sectoral policies and programs are required to mitigate the negative impacts of high ambient temperatures on maternal and neonatal health in rural Kilifi and similar settings.

NICU sensory experiences associated with positive outcomes: an integrative review of evidence from 2015-2020

To inform changes to the Supporting and Enhancing NICU Sensory Experiences (SENSE) program, studies investigating sensory-based interventions in the NICU with preterm infants born ≤32 weeks were identified. Studies published between October 2015 to December 2020, and with outcomes related to infant development or parent well-being, were included in this integrative review. The systematic search used databases including MEDLINE, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, and Google Scholar. Fifty-seven articles (15 tactile, 9 auditory, 5 visual, 1 gustatory/olfactory, 5 kinesthetic, and 22 multimodal) were identified. The majority of the sensory interventions that were identified within the articles were reported in a previous integrative review (1995-2015) and already included in the SENSE program. New evidence has led to refinements of the SENSE program, notably the addition of position changes across postmenstrual age (PMA) and visual tracking starting at 34 weeks PMA.

The impact of kangaroo mother care on work of breathing and oxygen saturation in very low birth weight infants with respiratory insufficiency

BACKGROUND: Kangaroo mother care (KMC) is defined as prolonged skin to skin care between a mother and infant with the infant lying in prone position on mom’s chest. KMC decreases morbidity and mortality and promotes physiologic stability. The aim of this study is to measure work of breathing (WOB) during KMC in very low birth weight (VLBW) infants on non-invasive respiratory support. METHODS: A prospective observational pilot study was conducted comparing WOB indices during standard care (SC) and KMC. Respiratory inductive plethysmography (RIP) measured WOB indices non-invasively: phase angle and labored breathing index. VLBW infants who were stable on non-invasive respiratory support were randomized to receive RIP measurements during KMC or during SC first. Summary statistics and mixed linear models were used to compare WOB and vital signs. RESULTS: A total of 32 infants were consented for the study, data collection and analysis was completed on 28 infants. There were no significant differences in mean phase angle during KMC or SC (73.5±4.6 SE deg vs 66.8±3.9 SE deg, p = 0.25). No differences in WOB and vital signs were detected. Controlling for respiratory support or randomization/first location did not change the results. CONCLUSION: In this pilot cohort, infants demonstrated no differences in work of breathing indices or oxygen saturation during KMC or SC while receiving non-invasive respiratory support. KMC appears to be safe and well tolerated with no worsened WOB. Larger studies should be performed to confirm our findings.

Early Skin-to-Skin Contact Does Not Affect Cerebral Tissue Oxygenation in Preterm Infants <32 Weeks of Gestation

Aim: It was the aim of our study to determine the regional cerebral tissue oxygenation saturation (rcSO2) as an additional monitoring parameter during early skin-to-skin contact (SSC) in preterm infants with a gestational age of <32 gestational weeks. Methods: We conducted two observational convenience sample studies using additional monitoring with near-infrared spectroscopy (NIRS) in the first 120 h of life: (a) NIRS 1 (gestational age of 26 0/7 to 31 6/7 weeks) and (b) NIRS 2 (gestational age of 24 0/7 to 28 6/7 weeks). The rcSO2 values were compared between resting time in the incubator (period I), SSC (period II) and handling nursing care (period III). For the comparison, we separated the sequential effects by including a “wash-out phase” of 1 h between each period. Results: During the first 120 h of life 38/53 infants in NIRS 1 and 15/23 infants in NIRS 2 received SSC, respectively. We found no remarkable differences for rcSO2 values of NIRS 1 patients between SSC time and period I (95% confidence interval (CI) for the difference in %: SSC vs. period I [1; 3]). In NIRS 2, rcSO2 values during SSC were only 2% lower compared with period I [median [1. quartile; 3. quartile] in %; 78 [73; 82] vs. 80 [74; 85]] but were similar to period III [78 [72; 83]]. In a combined analysis, a small difference in rcSO2 values between SSC and resting times was found using a generalized linear mixed model that included gender and gestational age (OR 95% CI; 1.178 [1.103; 1.253], p < 0.0001). Episodes below the cut-off for “hypoxia”; e.g., <55%, were comparable during SSC and periods I and III (0.3–2.1%). No FiO2 adjustment was required in the vast majority of SSC episodes. Conclusions: Our observational data indicate that rcSO2 values of infants during SSC were comparable to rcSO2 values during incubator care and resting time. This additional monitoring supports a safe implementation of early SSC in extremely preterm infants in NICUs.

Hyperthermia and Heat Stress as Risk Factors for Sudden Infant Death Syndrome: A Narrative Review

BACKGROUND AND OBJECTIVES

Heat stress and hyperthermia are common findings in sudden infant death syndrome (SIDS) victims. It has been suggested that thermal stress can increase the risk of SIDS directly via lethal hyperthermia or indirectly by altering autonomic functions. Major changes in sleep, thermoregulation, cardiovascular function, and the emergence of circadian functions occur at the age at which the risk of SIDS peaks-explaining the greater vulnerability at this stage of development. Here, we review the literature data on (i) heat stress and hyperthermia as direct risk factors for SIDS, and (ii) the indirect effects of thermal loads on vital physiological functions.

RESULTS

Various situations leading to thermal stress (i.e., outdoors temperatures, thermal insulation from clothing and bedding, the prone position, bed-sharing, and head covering) have been analyzed. Hyperthermia mainly results from excessive clothing and bedding insulation with regard to the ambient thermal conditions. The appropriate amount of clothing and bedding thermal insulation for homeothermia requires further research. The prone position and bed-sharing do not have major thermal impacts; the elevated risk of SIDS in these situations cannot be explained solely by thermal factors. Special attention should be given to brain overheating because of the head's major role in body heat losses, heat production, and autonomic functions. Thermal stress can alter cardiovascular and respiratory functions, which in turn can lead to life-threatening events (e.g., bradycardia, apnea with blood desaturation, and glottal closure). Unfortunately, thermal load impairs the responses to these challenges by reducing chemosensitivity, arousability, and autoresuscitation. As a result, thermal load (even when not lethal directly) can interact detrimentally with vital physiological functions.

CONCLUSIONS

With the exception of excessive thermal insulation (which can lead to lethal hyperthermia), the major risk factors for SIDS appears to be associated with impairments of vital physiological functions when the infant is exposed to thermal stress.

Parent-infant skin-to-skin contact reduces the electrical activity of the diaphragm and stabilizes respiratory function in preterm infants

BACKGROUND

The physiological benefit of parent-infant skin-to-skin contact (SSC) is uncertain for preterm infants with ventilatory support. We aimed to investigate whether SSC stabilizes the respiration compared to incubator care in mechanically ventilated preterm infants.

METHODS

The prospective observational study was performed in Turku University Hospital, Finland. Preterm infants were eligible if they were born before 36 weeks gestation and received respiratory support with either invasive or non-invasive neurally adjusted ventilatory assist (NAVA). SSC was applied as soon as possible after birth. Respiratory variables were collected from the ventilator log data, and SSC episodes were compared with matched control periods during incubator care.

RESULTS

A total of 167 episodes of SSC were recorded from 17 preterm infants: 138 episodes during invasive NAVA and 29 episodes during non-invasive NAVA. During invasive NAVA, peak electrical activity of the diaphragm (Edi), minimum Edi, respiratory rate, time on backup ventilation, peak inspiratory pressure, and mean airway pressure were significantly lower in SSC than in incubator care. During non-invasive NAVA, peak Edi, minimum Edi, time on backup ventilation, and peak inspiratory pressure were significantly lower in SSC than in incubator care.

CONCLUSIONS

SSC stabilized and improved the respiratory physiology in mechanically ventilated preterm infants.

IMPACT

Skin-to-skin contact reduced work of breathing compared to incubator care in mechanically ventilated preterm infants. Skin-to-skin contact reduced the need for backup ventilation during neurally adjusted ventilatory assist in preterm infants. Skin-to-skin contact among ventilated preterm infants was not only safe but also stabilized and improved their respiratory physiology.

Physiological responses to cuddling babies with hypoxic-ischaemic encephalopathy during therapeutic hypothermia: an observational study

OBJECTIVES

To determine whether parents cuddling infants during therapeutic hypothermia (TH) would affect cooling therapy, cardiorespiratory or neurophysiological measures. The secondary aim was to explore parent-infant bonding, maternal postnatal depression and breastfeeding.

DESIGN

Prospective observational study.

SETTING

Two tertiary neonatal intensive care units (NICU).

PARTICIPANTS

Parents and their term-born infants (n=27) receiving TH and intensive care for neonatal hypoxic-ischaemic encephalopathy.

INTERVENTIONS

Cuddling up to 2 hours during TH using a standard operating procedure developed in the study (CoolCuddle).

MAIN OUTCOME MEASURES

Mean difference in temperature, cardiorespiratory and neurophysiological variables before, during and after the cuddle. Secondary outcomes were parental bonding, maternal postnatal depression and breastfeeding.

RESULTS

During 70 CoolCuddles (115 cumulative hours), there were measurable increases in rectal temperature (0.07°C (0.03 to 0.10)) and upper margin of amplitude-integrated electroencephalogram (1.80 µV (0.83 to 2.72)) and decreases in oxygen saturations (-0.57% (-1.08 to -0.05)) compared with the precuddle period. After the cuddle, there was an increase in end-tidal CO₂ (0.25 kPa (95% CI 0.14 to 0.35)) and mean blood pressure (4.09 mm Hg (95% CI 0.96 to 7.21)) compared with the precuddle period. From discharge to 8 weeks postpartum, maternal postnatal depression declined (13 (56.5%) vs 5 (23.8%), p=0.007); breastfeeding rate differed (71% vs 50%, p=0.043), but was higher than national average at discharge (70% vs 54.6%) and mother-infant bonding (median (IQR): 3 (0-6) vs 3 (1-4)) remained stable.

CONCLUSION

In this small study, CoolCuddle was associated with clinically non-significant, but measurable, changes in temperature, cardiorespiration and neurophysiology. No infant met the criteria to stop the cuddles or had any predefined adverse events. CoolCuddle may improve breastfeeding and requires investigation in different NICU settings.

Kangaroo Mother Care Reduces Noninvasive Ventilation and Total Oxygen Support Duration in Extremely Low Birth Weight Infants

OBJECTIVE

Evidence on the safety and influence of kangaroo mother care (KMC) in extremely low birth weight infants (ELBWIs) on ventilation is lacking.

STUDY DESIGN

This is a retrospective cohort study performed in 145 ELBWIs on noninvasive mechanical ventilation from a tertiary center.

RESULTS

The duration of nasal intermittent positive pressure ventilation (nIPPV) and continuous positive airway pressure (CPAP) ventilation was significantly shorter in infants with KMC compared with infants without (21 vs. 13.5 days, p = 0.001 and 29.5 days vs. 20.5 days, p = 0.001, respectively). The frequency of apnea during hospital stay was fewer in KMC infants, compared with no KMC (23 vs. 20 times, p = 0.002). Multiple linear regression analysis showed that KMC was an independent protective factor for shortening nIPPV/CPAP duration (β = -9.90, 95% confidence interval [CI] [-13.20, -6.60], p < 0.001), total supplemental oxygen support (β = -10.52, 95% CI [-16.73, -4.30], p = 0.001), and reducing times of apneas (β = -5.88, 95% CI [-8.56, -3.21], p < 0.001).

CONCLUSION

KMC benefits ELBWIs by shortening nIPPV/CPAP ventilation duration and total supplemental oxygen support, and reducing the frequency of apneas.

Kangaroo mother care alters chromogranin A and perfusion index in preterm babies

BACKGROUND

While providing various benefits, concerns about the potential risks of kangaroo mother care, or skin-to-skin contact (SSC), between mother and her preterm infant hinder its widespread implementation in some resource- rich countries. In neonates, salivary chromogranin A (s-CgA) is elevated upon exposure to stress, whereas the perfusion index (PI) is associated with hemodynamics and peripheral perfusion. Here, we investigated the effects of SSC on s-CgA and the PI in preterm infants.

METHODS

Twelve infants were enrolled in the study. Factors associated with baseline s-CgA were analyzed. Baseline s-CgA and the level after SSC were compared. Secreted IgA in the saliva was compared as the control. The PI before, throughout, and after SSC were compared.

RESULTS

Baseline s-CgA was significantly lower in infants who were supplemented with baby formula milk in addition to breast milk before SSC (n = 2) compared with those fed with their mother's breast milk alone (n = 10, P = 0.03). SSC significantly decreased s-CgA in babies who were fed breast milk only before SSC (n = 10, P = 0.01) but not in those supplemented with formula milk before SSC (n = 2). Secreted IgA in saliva was not affected by SSC. The PI was significantly elevated during SSC (P = .01).

CONCLUSION

Our data indicate that SSC can reduce s-CgA levels when combined with mother's breast milk and increase the PI in preterm infants, thereby providing additional evidence of the benefit of SSC.

Skin-to-skin care alters regional ventilation in stable neonates

OBJECTIVE

Skin-to-skin care (SSC) has proven psychological benefits; however, the physiological effects are less clearly defined. Regional ventilation patterns during SSC have not previously been reported. This study aimed to compare regional ventilation indices and other cardiorespiratory parameters during prone SSC with supine and prone position cot-nursing.

DESIGN

Prospective observational study.

SETTING

Single quaternary neonatal intensive care unit in Australia.

PATIENTS

20 infants spontaneously breathing (n=17) or on non-invasive ventilation (n=3), with mean (SD) gestational age at birth of 33 (5) weeks.

INTERVENTIONS

Thirty-minute episodes of care in each position: supine cot care, prone SSC and prone cot care preceding a 10 min period of continuous electrical impedance tomography measurements of regional ventilation.

MAIN OUTCOME MEASURES

In each position, ventral-dorsal and right-left centre of ventilation (CoV), percentage of whole lung ventilation by region and percentage of apparent unventilated lung regions were determined. Heart and respiratory rates, oxygen saturation and axillary temperature were also measured.

RESULTS

Heart and respiratory rates, oxygen saturation, temperature and right-left lung ventilation did not differ between the three positions (mixed-effects model). Ventilation generally favoured the dorsal lung, but the mean (95% CI) ventrodorsal CoV was -2.0 (-0.4 to -3.6)% more dorsal during SSC compared with prone. Supine position resulted in 5.0 (1.5 to 5.3)% and 4.5 (3.9 to 5.1)% less apparently unventilated lung regions compared with SSC and prone, respectively.

CONCLUSIONS

In clinically stable infants, SSC generates a distinct regional ventilation pattern that is independent of prone position and results in greater distribution of ventilation towards the dorsal lung.

Systematic Review of the Effects of Skin-to-Skin Care on Short-Term Physiologic Stress Outcomes in Preterm Infants in the Neonatal Intensive Care Unit

BACKGROUND

Infants in the neonatal intensive care unit (NICU) are exposed to many stressors. There is growing evidence that chronic stress early in life has long-term neurodevelopmental implications. Skin-to-skin care (SSC) is an intervention used to reduce stress in the NICU.

CLINICAL QUESTION

In premature infants in the NICU, what is the available evidence that SSC improves short-term physiologic stress outcomes compared with incubator care?

SEARCH STRATEGY

PubMed and CINAHL were searched for terms related to SSC, stress, physiology, and premature infants. Of 1280 unique articles, 19 were identified that reported on research studies comparing SSC with incubator care in the NICU and reported stress-related physiologic outcome measures.

RESULTS

Although there have been some mixed findings, the research supports that SSC improves short-term cardiorespiratory stress outcomes compared with incubator care. The evidence is clearer for studies reporting stress hormone outcomes, with strong evidence that SSC reduces cortisol and increases oxytocin levels in preterm infants.

IMPLICATIONS FOR PRACTICE AND RESEARCH

SSC is safe and has stress-reducing benefits. SSC should be considered an essential component to providing optimal care in the NICU. More research is needed to determine the timing of initiation, duration, and frequency of SSC to optimize the stress-reducing benefits. Future research should include the most fragile infants, who are most likely to benefit from SSC, utilize power analyses to ensure adequate sample sizes, and use sophisticated data collection and analysis techniques to more accurately evaluate the effect of SSC on infants in the NICU.

Necrotizing enterocolitis: It's not all in the gut

Necrotizing enterocolitis is the leading cause of death due to gastrointestinal disease in preterm neonates, affecting 5–12% of neonates born at a very-low birth weight. Necrotizing enterocolitis can present with a slow and insidious onset, with some neonates displaying early symptoms such as feeding intolerance. Treatment during the early stages includes bowel rest and careful use of antibiotics, but surgery is required if pneumoperitoneum and intestinal perforation occur. Mortality rates among neonates requiring surgery are estimated to be 20–30%, mandating the development of non-invasive and reliable biomarkers to predict necrotizing enterocolitis before the onset of clinical signs. Such biomarkers would allow at-risk neonates to receive maximal preventative therapies such as careful nutritional consideration, probiotics, and increased skin-to-skin care.

Impact statement

Necrotizing enterocolitis (NEC) is a devastating gastrointestinal disease; its high mortality rate mandates the development of non-invasive biomarkers to predict NEC before its onset. This review summarizes the pathogenesis, prevention, unresolved issues, and long-term outcomes of NEC.

Automated Detection of Infant Holding Using Wearable Sensing: Implications for Developmental Science And Intervention

Physical contact is critical for children's physical and emotional growth and well-being. Previous studies of physical contact are limited to relatively short periods of direct observation and self-report methods. These methods limit researchers' understanding of the natural variation in physical contact across families, and its specific impacts on child development. In this study we develop a mobile sensing platform that can provide objective, unobtrusive, and continuous measurements of physical contact in naturalistic home interactions. Using commercially available motion detectors, our model reaches an accuracy of 0.870 (std: 0.059) for a second-by-second binary classification of holding. In addition, we detail five assessment scenarios applicable to the development of activity recognition models for social science research, where required accuracy may vary as a function of the intended use. Finally, we propose a grand vision for leveraging mobile sensors to access high-density markers of multiple determinants of early parent-child interactions, with implications for basic science and intervention.

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

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

Cerebral oxygenation during skin-to-skin care in preterm infants not receiving respiratory support

OBJECTIVE

Skin-to-skin care (SSC) has proven benefits in preterm infants, but increased hypoxic and bradycardic events have been reported. This may make clinicians hesitant to recommend SSC as standard care. We hypothesised that regional cerebral oxygenation (rStO₂) measured with near infrared spectroscopy is not worse during SSC compared with standard incubator care.

DESIGN

Prospective, observational, non-inferiority study.

SETTING

Single tertiary perinatal centre in Australia.

PATIENTS

Forty preterm infants (median (IQR) 30.6 (29.1-31.7) weeks' gestation) not receiving respiratory support were studied on day 14 (8-38).

INTERVENTIONS

Recordings during 90 min of incubator care, followed by 90 min of SSC. Each infant acted as their own control and caregivers were blinded to the rStO₂ measurements.

MAIN OUTCOME MEASURES

The primary outcome was the mean difference in rStO₂ between SSC and incubator care. The prespecified margin of non-inferiority was -1.5%. Secondary outcomes included heart rate (HR), peripheral oxygen saturation (SpO₂), time in quiet sleep, temperature and hypoxic (SpO₂ <80% for >5 s) or bradycardic events (HR <80 bpm for >5 s) and time spent in cerebral hypoxia (rStO₂<55%) and hyperoxia (rStO₂>85%).

RESULTS

Mean (SD) rStO₂ was lower during SSC compared with incubator care: 73.6 (6.0)% vs 74.8 (4.6)%, mean difference (95% CI) 1.3 (2.2 to 0.4)%. HR was 5 bpm higher, SpO₂ 1% lower and time in quiet sleep 24% longer during SSC. Little evidence of a difference was observed in temperature. The number of hypoxic or bradycardic events as well as the proportion of time spent in cerebral hypoxia and hyperoxia was very low in both periods.

CONCLUSIONS

Mean rStO₂ was marginally lower during SSC without observed differences in hypoxic or bardycardic events but an increase in time spent in quiet sleep.

TRIAL REGISTRATION NUMBER

This trial is linked to Australian New Zealand Clinical Trials Registry: identifier 12616000240448. It was registered pre-results.

The effect of skin-to-skin care on cerebral oxygenation during nasogastric feeding of preterm infants

AIM

To describe cerebral oxygenation during gavage feeding of preterm infants during incubator and skin-to-skin care.

METHODS

Further analysis of data from two crossover studies comparing cerebral oxygenation, heart rate and oxygen saturation during skin-to-skin care with incubator care. Data were analysed in three epochs; 10 minutes prefeed, during-feed and 10 minutes postfeed. Measurements from infants fed during incubator care were compared with those obtained during skin-to-skin care.

RESULTS

In 39 infants [median (IQR) 27.8 (26.1-30.0) weeks' gestation], there was no difference in cerebral oxygenation between pre-, during- and postfeed. Heart rate increased by three beats per minute postfeed compared with during-feed. Twenty infants received two gavage feeds, one feed in the incubator and another during skin-to-skin care. There was no difference in cerebral oxygenation and heart rate; peripheral oxygen saturation decreased by 3% during feeding whilst skin-to-skin care compared with feeding in the incubator.

CONCLUSION

Cerebral oxygenation remained stable before, during and after gavage feeding in an incubator and during skin-to-skin care. The small decrease in oxygen saturation whilst receiving gavage feeding during skin-to-skin care is unlikely to be clinically important, providing reassurance that preterm infants maintain physiological stability during skin-to-skin care.

Insulin sensitivity, leptin, adiponectin, resistin, and testosterone in adult male and female rats after maternal-neonatal separation and environmental stress

Care of premature infants often requires parental and caregiver separation, particularly during hypoxic and hypothermic episodes. We have established a neonatal rat model of human prematurity involving maternal-neonatal separation and hypoxia with spontaneous hypothermia prevented by external heat. Adults previously exposed to these neonatal stressors show a sex difference in the insulin and glucose response to arginine stimulation suggesting a state of insulin resistance. The current study used this cohort of adult rats to evaluate insulin resistance [homeostatic model assessment of insulin resistance (HOMA-IR)], plasma adipokines (reflecting insulin resistance states), and testosterone. The major findings were that daily maternal-neonatal separation led to an increase in body weight and HOMA-IR in adult male and female rats and increased plasma leptin in adult male rats only; neither prior neonatal hypoxia (without or with body temperature control) nor neonatal hypothermia altered subsequent adult HOMA-IR or plasma adiponectin. Adult male-female differences in plasma leptin were lost with prior exposure to neonatal hypoxia or hypothermia; male-female differences in resistin were lost in the adults that were exposed to hypoxia and spontaneous hypothermia as neonates. Exposure of neonates to daily hypoxia without spontaneous hypothermia led to a decrease in plasma testosterone in adult male rats. We conclude that neonatal stressors result in subsequent adult sex-dependent increases in insulin resistance and adipokines and that our rat model of prematurity with hypoxia without hypothermia alters adult testosterone dynamics.

Skin-to-skin care in preterm infants receiving respiratory support does not lead to physiological instability

OBJECTIVE

Providing skin-to-skin care (SSC) to preterm infants is standard practice in many neonatal intensive care units. There are conflicting reports on the stability of oxygen saturation (SpO₂) during SSC, which may create a barrier to a wider implementation of SSC to infants receiving respiratory support. Regional cerebral oxygenation (rcO₂) measured using near-infrared spectroscopy can serve as a surrogate parameter for cerebral oxygen delivery and consumption. We hypothesised that rcO₂ during SSC would be similar to standard care in preterm infants receiving respiratory support.

DESIGN

Prospective observational non-inferiority study.

SETTING

Single tertiary perinatal centre in Australia.

PATIENTS

Forty preterm infants (median (IQR) of 27.6 (26.0-28.9) weeks' gestation) receiving respiratory support were studied on day 8 (5-18).

INTERVENTIONS

Ninety minutes of SSC, with infants in incubators acting as their own control. Parents and caregivers were blinded to the measurements.

MAIN OUTCOME MEASURES

Mean difference in rcO₂ between SSC and incubator care; as well as heart rate (HR), SpO₂, fraction of inspired oxygen (FiO₂) and temperature, were compared using a paired t-test.

RESULTS

rcO₂ was similar during SSC (mean (SD) 74.9 (6.5)%)% compared with incubator care (74.7 (6.1)%, mean difference (95% CI) 0.2 (-0.8 to 1.1)%, p=0.71). No clinically important differences in HR, SpO₂, FiO₂ or temperature were observed in the whole cohort and by mode of respiratory support (endotracheal tube mechanical ventilation, continuous positive airway pressure and high-flow nasal cannulae).

CONCLUSIONS

Cerebral oxygenation and other physiological measurements in ventilated preterm infants did not differ between SSC and incubator care.

TRIAL REGISTRATION NUMBER

12615000959572.

Enhancing sensory experiences for very preterm infants in the NICU: an integrative review

OBJECTIVE

Very preterm infants hospitalized in the neonatal intensive care unit (NICU) experience alterations in sensory experiences. Defining types, timing and frequency of sensory-based interventions that optimize outcomes can inform environmental modifications. The objective of this study was to conduct an integrative review on sensory-based interventions used with very preterm infants in the NICU to improve infant and parent outcomes.

STUDY DESIGN

The data sources include MEDLINE, CINAHL, Cochrane Library and Google Scholar. Studies were identified that used sensory-based interventions in the NICU with preterm infants born ⩽32 weeks gestation, were published in a peer-reviewed journal between 1995 and 2015, and measured outcomes related to infant and parent outcomes. Studies were extracted from electronic databases and hand-searched from identified reference lists.

RESULTS

Eighty-eight articles were identified (31 tactile, 12 auditory, 3 visual, 2 kinesthetic, 2 gustatory/olfactory and 37 multimodal). There was evidence to support the use of kangaroo care, music and language exposure, and multimodal interventions starting at 25 to 28 weeks postmenstrual age. These interventions were related to better infant development and lower maternal stress, but not all findings were consistent. Limitations included lack of consistent outcome measures, study quality and gaps in the literature.

CONCLUSIONS

Most research identified interventions that were done for short periods of time. It is unclear what the potential is for improving outcomes if positive sensory exposures occur consistently throughout NICU hospitalization. Until more research defines appropriate sensory-based interventions to use with infants born very preterm in the NICU, information from this review can be combined with expert opinion and parent/family values to determine best practice.

Skin-to-skin care for procedural pain in neonates

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Kangaroo Mother Care and Neonatal Outcomes: A Meta-analysis

CONTEXT

Kangaroo mother care (KMC) is an intervention aimed at improving outcomes among preterm and low birth weight newborns.

OBJECTIVE

Conduct a systematic review and meta-analysis estimating the association between KMC and neonatal outcomes.

DATA SOURCES

PubMed, Embase, Web of Science, Scopus, African Index Medicus (AIM), Latin American and Caribbean Health Sciences Information System (LILACS), Index Medicus for the Eastern Mediterranean Region (IMEMR), Index Medicus for the South-East Asian Region (IMSEAR), and Western Pacific Region Index Medicus (WPRIM).

STUDY SELECTION

We included randomized trials and observational studies through April 2014 examining the relationship between KMC and neonatal outcomes among infants of any birth weight or gestational age. Studies with <10 participants, lack of a comparison group without KMC, and those not reporting a quantitative association were excluded.

DATA EXTRACTION

Two reviewers extracted data on study design, risk of bias, KMC intervention, neonatal outcomes, relative risk (RR) or mean difference measures.

RESULTS

1035 studies were screened; 124 met inclusion criteria. Among LBW newborns, KMC compared to conventional care was associated with 36% lower mortality(RR 0.64; 95% [CI] 0.46, 0.89). KMC decreased risk of neonatal sepsis (RR 0.53, 95% CI 0.34, 0.83), hypothermia (RR 0.22; 95% CI 0.12, 0.41), hypoglycemia (RR 0.12; 95% CI 0.05, 0.32), and hospital readmission (RR 0.42; 95% CI 0.23, 0.76) and increased exclusive breastfeeding (RR 1.50; 95% CI 1.26, 1.78). Newborns receiving KMC had lower mean respiratory rate and pain measures, and higher oxygen saturation, temperature, and head circumference growth.

LIMITATIONS

Lack of data on KMC limited the ability to assess dose-response.

CONCLUSIONS

Interventions to scale up KMC implementation are warranted.

Kangaroo care: cardio-respiratory relationships between the infant and caregiver

BACKGROUND

Kangaroo care, i.e., skin-to-skin cohabitation (SSC) between an infant and caregiver, is often used in neonatal intensive care units to promote bonding, breastfeeding and infant growth. The direct salutary effects of SSC on cardio-respiratory control in preterm infants remain equivocal; some reports suggest improved breathing stability, others indicate worsening of apnea, bradycardia and hypoxemia.

AIM

The purpose of this study was to investigate physiological relationships between the infant and caregiver during SSC. We hypothesized that respiratory stability of the premature infant is influenced by the caregiver's heartbeat.

DESIGN

A prospective study was performed in eleven preterm infants (6 female; mean PCA 32 wks). SSC was compared to a preceding incubator-control period (CTL) matched for time from feed and condition duration. Abdominal respiratory movement, electrocardiogram, skin temperature and blood-oxygen levels were recorded from the infant and the caregiver.

RESULTS

During CTL, infant interbreath interval variance (IBIv; respiratory instability) was directly related to its own heart rate variance (HRv; rho=0.770, p=0.009). During SSC, infant IBIv and apnea incidence were each related to caregiver HRv (rho 0.764, p=0.006; rho 0.677, p=0.022, respectively). Infant cardio-respiratory coupling was also enhanced during SSC compared to CTL in the eupneic frequency range (0.7-1.5 Hz, p=0.018) and reduced for slower frequencies (0.15-0.45 Hz; p=0.036).

CONCLUSION

These findings suggest that during SSC, respiratory control of the premature infant is influenced by the caregiver's cardiac rhythm. We propose that the caregiver's heartbeat causes sensory perturbations of the infant via somatic or other afferents, revealing a novel cohabitation-induced feed-back mechanism of respiratory control in the neonate.

The effects of skin-to-skin care on the diaphragmatic electrical activity in preterm infants

BACKGROUND

Skin-to-skin care (SSC) is widely used in neonatal intensive care units due to its positive effects on infant physiology and parent-infant interaction.

AIMS

We investigated the safety and the effect of SSC on the diaphragm electrical activity (EAdi) in premature infants recovering from respiratory distress syndrome treated on noninvasive neurally adjusted respiratory assist.

STUDY DESIGN

An observational cross-over study design was used. The infants were evaluated during SSC and in both prone and supine positions before and after SSC during a 9-hour study period. The EAdi was measured via miniaturized sensors incorporated into a feeding tube.

SUBJECTS

Seventeen premature infants with a mean age of 20d (range, 2-43d) were studied. Their mean birth weight was 900g (490-1845g) and mean gestational age at birth 28wk (25-32wk).

OUTCOME MEASURES

Under each condition, EAdi peak (representing tidal, neural inspiratory effort) and EAdi minimum (representing neural expiratory activity) were numerically quantified. Oxygen saturation, heart rate, and apnea were recorded.

RESULTS

The mean EAdi minimum values were lower during SSC and prone position. In addition, a tendency towards lower EAdi peak values was found during SSC. There were no differences in the occurrence of apnea between the study phases.

CONCLUSIONS

SSC is safe and it is not associated with increased neural activity of the diaphragm. On the contrary, low EAdi minimum values were registered reflecting more complete diaphragmatic de-activation between respiratory cycles.

Effects of daily kangaroo care on cardiorespiratory parameters in preterm infants

BACKGROUND/AIMS

Kangaroo care (KC) has possible benefits for promoting physiological stability and positive developmental outcomes in preterm infants. The purpose of this study was to compare bradycardia and oxygen desaturation events in preterm infants in standard incubator care versus KC.

METHODS

Thirty-eight infants 27 to 30 weeks gestational age were randomly assigned to 2 hours of KC daily between days of life 5 to 10 or to standard incubator care. Infants were monitored for bradycardia (heart rate <80) or oxygen desaturation (<80%). Analysis of hourly events was based on three sets of data: standard care group 24 hours daily, KC group during incubator time 22 hours daily, and KC group during holding time 2 hours daily.

RESULTS

The KC group had fewer bradycardia events per hour while being held compared to time spent in an incubator (p = 0.048). The KC group also had significantly fewer oxygen desaturation events while being held than while in the incubator (p = 0.017) and significantly fewer desaturation events than infants in standard care (p = 0.02).

CONCLUSION

KC reduces bradycardia and oxygen desaturation events in preterm infants, providing physiological stability and possible benefits for neurodevelopmental outcomes.

Skin-to-skin care for procedural pain in neonates

BACKGROUND

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

OBJECTIVES

The primary objectives were to determine the effect of SSC alone on pain from medical or nursing procedures in neonates undergoing painful procedures compared to no intervention, sucrose or other analgesics, or additions to simple SSC such as rocking; and the effects of the amount of SSC (duration in minutes) and the method of administration (who provided the SSC, positioning of caregiver and neonate pair).The secondary objectives were to determine the incidence of untoward effects of SSC and to compare the SSC effect in different postmenstrual age subgroups of infants.

SEARCH METHODS

The standard methods of the Cochrane Neonatal Collaborative Review Group were used. Databases searched in August 2011: Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library); Evidence-Based Medicine Reviews; MEDLINE (1950 onwards); PubMed (1975 onwards); EMBASE (1974 onwards); CINAHL (1982 onwards); Web of Science (1980 onwards); LILACS database (1982 onwards); SCIELO database (1982 onwards); PsycInfo (1980 onwards); AMED (1985 onwards); Dissertation-Abstracts International (1980 onwards). Searches were conducted throughout September 2012.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

Nineteen studies (n = 1594 infants) were included. Fifteen studies (n = 744) used heel lance as the painful procedure, one study combined venepuncture and heel stick (n = 50), two used intramuscular injection, and one used 'vaccination' (n = 80). The studies that were included were generally strong and free from bias.Eleven studies (n = 1363) compared SSC alone to a no-treatment control. Although 11 studies measured heart rate during painful procedures, data from only four studies (n = 121) could be combined to give a mean difference (MD) of 0.35 beats per minute (95% CI -6.01 to 6.71). Three other studies that were not included in meta-analyses also reported no difference in heart rate after the painful procedure. Two studies reported heart rate variability outcomes and found no significant differences. Five studies used the Premature Infant Pain Profile (PIPP) as a primary outcome, which favoured SCC at 30 seconds (n = 268) (MD -3.21, 95% CI -3.94 to -2.48), 60 seconds (n = 164) (MD -1.85, 95% CI -3.03 to -0.68), and 90 seconds (n = 163) (MD -1.34, 95% CI -2.56 to -0.13), but at 120 seconds (n = 157) there was no difference. No studies provided findings on return of heart rate to baseline level, oxygen saturation, cortisol levels, duration of crying, and facial actions that could be combined for analysis.Eight studies compared SSC to another intervention with or without a no-treatment control. Two cross-over studies (n = 80) compared mother versus other provider on PIPP scores at 30, 60, 90, and 120 seconds with no significant difference. When SSC was compared to other interventions, there were not enough similar studies to pool results in an analysis. One study compared SSC with and without dextrose and found that the combination was most effective and that SSC alone was more effective than dextrose alone. Similarly, in another study SSC was more effective than oral glucose for heart rate but not oxygen saturation. SSC either in combination with breastfeeding or alone was favoured over a no-treatment control, but was not different to breastfeeding. There were not enough participants with similar outcomes and painful procedures to compare age groups or duration of SSC. No adverse events were reported in any of the studies.

AUTHORS' CONCLUSIONS

SSC appears to be effective, as measured by composite pain indicators and including both physiological and behavioural indicators, and safe for a single painful procedure such as a heel lance. Purely behavioural indicators tended to favour SSC but there remains questionable bias regarding behavioural indicators. Physiological indicators were typically not different between conditions. Only two studies compared mother providers to others, with non-significant results. There was more heterogeneity in the studies with behavioural or composite outcomes. There is a need for replication studies that use similar, clearly defined outcomes. New studies examining optimal duration of SSC, gestational age groups, repeated use, and long-term effects of SSC are needed.

Trial of repeated analgesia with Kangaroo Mother Care (TRAKC Trial)

BACKGROUND

Skin-to-skin contact (SSC) between mother and infant, commonly referred to as Kangaroo Mother Care (KMC), is recommended as an intervention for procedural pain. Evidence demonstrates its consistent efficacy in reducing pain for a single painful procedure. The purpose of this study is to examine the sustained efficacy of KMC, provided during all routine painful procedures for the duration of Neonatal Intensive Care Unit (NICU) hospitalization, in diminishing behavioral pain response in preterm neonates. The efficacy of KMC alone will be compared to standard care of 24% oral sucrose, as well as the combination of KMC and 24% oral sucrose.

METHODS/DESIGN

Infants admitted to the NICU who are less than 36 6/7 weeks gestational age (according to early ultrasound), that are stable enough to be held in KMC, will be considered eligible (N = 258). Using a single-blinded randomized parallel group design, participants will be assigned to one of three possible interventions: 1) KMC, 2) combined KMC and sucrose, and 3) sucrose alone, when they undergo any routine painful procedure (heel lance, venipuncture, intravenous, oro/nasogastric insertion). The primary outcome is infant's pain intensity, which will be assessed using the Premature Infant Pain Profile (PIPP). The secondary outcome will be maturity of neurobehavioral functioning, as measured by the Neurobehavioral Assessment of the Preterm Infant (NAPI). Gestational age, cumulative exposure to KMC provided during non-pain contexts, and maternal cortisol levels will be considered in the analysis. Clinical feasibility will be accounted for from nurse and maternal questionnaires.

DISCUSSION

This will be the first study to examine the repeated use of KMC for managing procedural pain in preterm neonates. It is also the first to compare KMC to sucrose, or the interventions in combination, across time. Based on the theoretical framework of the brain opioid theory of attachment, it is expected that KMC will be a preferred standard of care. However, current pain management guidelines are based on minimal data on repeated use of either intervention. Therefore, regardless of the outcomes of this study, results will have important implications for guidelines and practices related to management of procedural pain in preterm infants.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01561547.

Nonpharmacological management of pain during common needle puncture procedures in infants: current research evidence and practical considerations

All infants undergo painful procedures involving skin puncture as part of routine medical care. Pain from needle puncture procedures is suboptimally managed. Numerous nonpharmacologic interventions are available for these painful procedures, including swaddling, holding, skin-to-skin care, pacifier, sweet-tasting solutions, and breast-feeding. Adoption of nonpharmacologic pain-relieving interventions into routine clinical practice is feasible and should be a standard of care in the delivery of quality health care for infants. This review summarizes current knowledge about the epidemiology of pain from common needle puncture procedures in infants, the effectiveness of nonpharmacologic interventions, implementation considerations, and unanswered questions for future research.

Frequency of Premature Infant Engagement and Disengagement Behaviors During Two Maternally Administered Interventions

Although sensitive maternal behaviors improve later quality of mother-infant interaction and subsequently infant development, little is known regarding how an intervention might promote early premature infant social interactive behavior. This study compared the frequency of premature infant engagement and disengagement behaviors during two maternally administered interventions, the multi-sensory auditory, tactile, visual and vestibular intervention (ATVV) and kangaroo care (KC) for 26 infants between 31 and 46 weeks PMA. The ATVV intervention elicited more disengagement (M = 24 vs. 12, p = .0003), trended toward more engagement (M = 21 vs. 15.7, p = .06) and more potent engagement (M = 24 vs. 12, p = .0003), subtle disengagement (M = 25 vs. 11.9, p < .0001), and potent disengagement (M = 22.9 vs. 14, p = . 006) behaviors than did KC. The ATVV intervention may be an intervention to promote the infant's learning how to regulate engagement and disengagement behaviors.

Respostas fisiológicas de recém-nascidos pré-termo submetidos ao Metódo Mãe-Canguru e a posição prona

O Ministério da Saúde recomenda e incentiva a Atenção Humanizada ao recém-nascido de baixo peso utilizando-se o Método Mãe-Canguru (MMC) nas unidades integrantes do Sistema Único de Saúde (SUS). O objetivo deste estudo foi avaliar e comparar as respostas fisiológicas entre o MMC e a posição prona (PP), em recém-nascidos pré-termo (RNPT). Foi feito um estudo de intervenção, realizado entre setembro e outubro de 2009, composto por 20 RNPT, de ambos os sexos, com idade gestacional entre 24 a 36 semanas, estáveis hemodinamicamente, sendo classificados como grupo I (MMC) e grupo II (PP). Foram consideradas as variáveis: frequência cardíaca (FC), frequência respiratória (FR), saturação periférica de oxigênio (SatO2) e temperatura corporal (T). As mensurações foram realizadas por três dias consecutivos, antes e 60 min após a aplicação das técnicas. No grupo PP, a FR aferida antes foi significativamente maior do que a aferida após a intervenção, nos 1º e 3º dias (p<0,0001; p<0,006); enquanto que, no MMC, a FR apresentou diferença significativa somente no 3º dia (p<0,006). A FC apresentou redução entre os momentos no 3º dia, nos grupos PP (p<0,02) e no MMC (p<0,04). No grupo PP, a variável SatO2 apresentou significativo aumento nos 1º (p<0,02) e 3º dias (p<0,02), entre os momentos de coleta, e no 3º dia do MMC (p<0,04). Não foram observadas alterações na FR, FC, T e SatO2 com a aplicação do MMC e PP, não havendo melhor desempenho em relação aos grupos. Observamos diminuição da FR após a aplicação do MMC e PP em momentos isolados e aumento da SatO2 no 3º dia após o MMC.

Effects of skin-to-skin contact on autonomic pain responses in preterm infants

The purpose of this randomized crossover trial was to determine the effects on autonomic responses in preterm infants of longer Kangaroo Care (30 minutes, KC30) and shorter KC (15 minutes, KC15) before and throughout heel stick compared with incubator care (IC). Beat-to-beat heart rate (HR) and spectral power analysis of heart rate variability, low frequency power (LF), high frequency power (HF), and LF/HF ratio were measured in 26 infants. HR changes from Baseline to Heel Stick were significantly less in KC30 and KC15 than in IC, and more infants had HR decrease in IC than in 2 KC conditions. In IC, LF and HF significantly increased from Baseline to Heel Stick and dropped from Heel Stick to Recovery; in 2 KC conditions, no changes across study phases were found. During Heel Stick, LF and HF were significantly higher in IC than in KC30. In all 3 conditions, LF/HF ratio decreased from Baseline to Heel Stick and increased to Recovery; no differences were found between IC and two KC conditions. Both longer and shorter KC before and throughout heel stick can stabilize HR response in preterm infants, and longer KC significantly affected infants' sympathetic and parasympathetic responses during heel stick compared with incubator care.

PERSPECTIVE

This study showed that KC has a significant effect on reducing autonomic pain responses in preterm infants. The findings support that KC is a safe and effective pain intervention in the neonatal intensive care unit.

Neonatal non-contact respiratory monitoring based on real-time infrared thermography

BACKGROUND

Monitoring of vital parameters is an important topic in neonatal daily care. Progress in computational intelligence and medical sensors has facilitated the development of smart bedside monitors that can integrate multiple parameters into a single monitoring system. This paper describes non-contact monitoring of neonatal vital signals based on infrared thermography as a new biomedical engineering application. One signal of clinical interest is the spontaneous respiration rate of the neonate. It will be shown that the respiration rate of neonates can be monitored based on analysis of the anterior naris (nostrils) temperature profile associated with the inspiration and expiration phases successively.

OBJECTIVE

The aim of this study is to develop and investigate a new non-contact respiration monitoring modality for neonatal intensive care unit (NICU) using infrared thermography imaging. This development includes subsequent image processing (region of interest (ROI) detection) and optimization. Moreover, it includes further optimization of this non-contact respiration monitoring to be considered as physiological measurement inside NICU wards.

RESULTS

Continuous wavelet transformation based on Debauches wavelet function was applied to detect the breathing signal within an image stream. Respiration was successfully monitored based on a 0.3°C to 0.5°C temperature difference between the inspiration and expiration phases.

CONCLUSIONS

Although this method has been applied to adults before, this is the first time it was used in a newborn infant population inside the neonatal intensive care unit (NICU). The promising results suggest to include this technology into advanced NICU monitors.

Randomized crossover trial of kangaroo care to reduce biobehavioral pain responses in preterm infants: a pilot study

Kangaroo care (KC), skin-to-skin contact between mother and infant, is a promising method for blunting pain responses. This crossover pilot tested KC effects on biobehavioral responses to heel stick in preterm infants (30-32 weeks' gestational age, 2-9 days old) measured by Premature Infant Pain Profile (PIPP) and salivary and serum cortisol. Mother-infant dyads were randomly assigned to KC heel stick (KCH) first or incubator heel stick (IH) first. Study 1 (80-min study, N = 18) tested the effect of 80 min of KC before and throughout the heel stick procedure versus incubator care. Study 2 (30-min study, N = 10) tested 30 min of KC before and throughout the heel stick versus incubator care. KCH and IH began during a premeasurement phase and continued through four data collection phases: baseline, heel warming, heel stick, and recovery. PIPP responses were measured every 30 s during data collection; salivary cortisol was measured at the end of baseline and recovery; and serum cortisol was measured during heel stick. Study 1 showed no differences between KCH and IH. Study 2 showed lower PIPP scores at four time points during recovery (p < .05 to p < .001), lower salivary cortisol at the end of recovery (p < .05), and lower serum cortisol during heel stick for the KCH condition (p < .05) as well as clinically lower PIPP scores in the KCH condition during heel stick. Thirty minutes of KC before and throughout the heel stick reduced biobehavioral responses to pain in preterm infants.

An innovative model for achieving breast-feeding success in infants with complex surgical anomalies

This manuscript describes an innovative nurse-driven continuous quality improvement project. Infants born with congenital surgical anomalies face significant challenges within the newborn period and human milk/breast-feeding may not be viewed as a priority. In many hospitals, nurses refer families to lactation consultants for all breast-feeding assistance and support. The Transition to Breast Pathway was developed on the basis of the evidence-based standards and protocols at The Children's Hospital of Philadelphia. The pathway consists of (1) initiation of pumping and maintenance of milk supply, (2) mouth care with human milk, (3) skin-to-skin care, (4) nonnutritive sucking at the breast, (5) transitioning to at breast feeds. A sample of 80 infants were enrolled in this project. Major results of the project are as follows: (1) mother's average milk supply was approximately 603 mL/d, (2) 71% (57/80) of the infants received mouth care with human milk, (3) 48% (38/80) mother/infant dyads performed skin-to-skin care, (4) 60% (35/58) of mother/infant dyads performed nonnutritive sucking at the breast, (5) 100% (58/58) of mother-infant dyads transitioned to breast prior to discharge. This continuous quality improvement project demonstrates that nurses can and should lead the process of transitioning infants to at breast feeds.

Skin-to-skin contact after cesarean delivery: an experimental study

BACKGROUND

The effectiveness of skin-to-skin contact (SSC) after vaginal delivery has been shown. After cesarean births, SSC is not done for practical and medical safety reasons because it is believed that infants may suffer mild hypothermia.

OBJECTIVE

The aim of this study was to compare mothers' and newborns' temperatures after cesarean delivery when SSC was practiced (naked baby except for a small diaper, covered with a blanket, prone on the mother's chest) with those when routine care was practiced (dressed, in the bassinet or in the mother's bed) in the 2 hours beginning when the mother returned from the operating room.

METHODS

An experimental, noninferiority adaptive trial was designed with four levels of analysis: 34 pairs of mothers and newborns, after elective cesarean delivery, were randomized to SSC (n = 17) or routine care (n = 17). Temporal artery temperature was taken with an infrared ray thermometer at half-hour intervals.

RESULTS

Compared with newborns who received routine care, SSC cesarean-delivered newborns were not at risk for hypothermia. The mean temperatures of both groups were almost identical: after 30 min, 36.1 degrees C for both groups (+/-0.4 degrees C for SSCs and +/-0.5 degrees C for the controls), and after 120 min, 36.2 degrees C +/- 0.3 degrees C for SSCs versus 36.4 degrees C +/- 0.7 degrees C for the controls (no significant differences). Time from delivery to the mothers' return to their room was 51 +/- 10 min. The SSC newborns attached to the breast earlier (nine SSC newborns and four controls after 30 min) were breast-fed (exclusively or prevalently) at discharge (13 SSCs and 11 controls) and at 3 months (11 SSCs and 8 controls), and the SSC mothers expressed high levels of satisfaction with the intervention.

DISCUSSION

Cesarean-delivered newborns who experienced SSC within 1 hour of delivery are not at risk for hypothermia.

Meta-analysis of physiological effects of skin-to-skin contact for newborns and mothers

BACKGROUND

Skin-to-skin care has been adopted all over the world, although physiological changes during or after it have not been evaluated very well. The purpose of the present study was therefore to investigate whether skin-to-skin contact for newborn babies and their mothers affects body temperature, heart rate and oxygen saturation of the babies.

METHODS

Studies investigating body temperature, heart rate and oxygen saturation of babies during and/or after skin-to-skin contact were systematically searched and reviewed. Meta-analyses to examine the effects and meta-regression analyses to investigate correlations between the effects and birthweight, duration of the care, environmental temperature, and resources of the setting, were conducted.

RESULTS

A total of 23 studies were included. Meta-analyses showed evidence of an increase in body temperature (weighted mean difference [WMD] 0.22 degrees C, P < 0.001) and a decrease in saturation of babies (WMD -0.60%; P= 0.01) during skin-to-skin care, compared with those before skin-to-skin care. Increase in body temperature was more evident in middle-low-income settings (WMD, 0.61 degrees C, P < 0.001) than high-income settings (WMD 0.20 degrees C, P < 0.001). Both the positive effect on body temperature and the negative effect on saturation were more marked in cold environments than where the environmental temperature was higher (WMD 0.18 degrees C, P < 0.001; WMD -0.82%, P= 0.02).

CONCLUSION

Skin-to-skin care is effective in increasing the body temperature of babies, especially where resources are limited and the environment is cold. Decreased oxygen saturation of the babies, however, warrants further prospective studies to confirm the findings.

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

BACKGROUND

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

AIM

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

STUDY DESIGN

A randomized cross-over trial.

SUBJECTS

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

OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Experience with Kangaroo mother care in a neonatal intensive care unit (NICU) in Chandigarh, India

OBJECTIVE

To study the feasibility and acceptability of Kangaroo mother care (KMC) on the low birth weight infants (LBWI) in the neonatal intensive care unit (NICU) by the mothers, family members and health care workers (HCW) and to observe its effect on the vital parameters of the babies.

METHOD

A observation in the NICU.

RESULTS

A total of 135 babies (74 boys and 61 girls) who completed minimum of 4 hrs of KMC/day, were included. The mean birth weight and gestation were 1460 gm and 30 week respectively. 47% babies started KMC within first week of age. Mean duration of KMC was 7 days (3-48) days. The O(2) saturation improved by 2-3%, temperature ( degrees C) rose from 36.75 +/- 0.19 to 37.23 +/- 0.25, respiration stabilized (p<0.05 for all) and heart rate dropped by 3-5 beats. No episodes of hypothermia or apnea were observed during KMC. KMC was accepted by 96 % mothers, 82% fathers and 84% other family members. 94% HCW considered it to be safe and conservative method of care of LBWI. Benefits of KMC on the babies' behavior and on maternal confidence and lactation were reported by 57%, 94% and 80% respectively. A decline in use of heating devices in the NICU was reported by 85% and 79% said it did not increase their work load.

CONCLUSION

KMC was found to be safe, effective and feasible method of care of LBWI even in the NICU settings. Positive attitudes were observed in mothers, families and HCW.

Cerebral oxygenation responses during kangaroo care in low birth weight infants

Background

Kangaroo care (KC) has been widely using to improve the care of low birth weight infants. However, very little is known about cerebral hemodynamics responses in low birth weight infants during KC intervention. The objective of this study was to elucidate the response of cerebral hemodynamics during KC in low birth weight infants.

Methods

Near infrared spectroscopy measured regional cerebral oxygenation (rSO₂), heart rate (HR), respiration rate (RR) measured by electrocardiogram, and percentages of oxygen saturation (SpO₂) measured by pulse oxymetry was monitored in 16 preterm infants (< 1600 g) in three sessions: before, during, and after KC. Using power spectral analysis, total power (TP), low-frequency (LF, 0.02–0.20 Hz) and high-frequency (HF, 0.20–0.50 Hz) bands, the ratio of LF/HF were calculated and normalized as %LF or %HF = LF or HF/TP × 100 (%).

Results

Significant differences were not observed in the mean rSO₂, HR, and SpO₂ throughout sessions; however, the TP of these parameters was significantly decreased during KC and increased after KC (p < 0.001). The %LF of LrSO₂ and RrSO₂ was decreased during KC (p < 0.05) with decreased %HF in RrSO₂ (p < 0.05). The %LF of HR was significantly increased during KC while %HF was decreased (p < 0.05). Mean and TP of RR was increased during KC (p < 0.01 respectively) with the increase of quiet sleep state (p < 0.05) and decreased after KC (p < 0.01). The %LF of RR was increased after KC (p < 0.05) with decreased %HF (p < 0.05); however, significant changes were not observed during KC.

Conclusion

KC intervention appears to have influence on cerebral hemodynamics as well as cardiorespiratory parameters. The results of rSO₂ and HR might be associated with quiet sleep states. The results of this study may indicate the contribution of KC intervention to the activation of central nervous system and brain function. Further study is needed to determine the underlying physiology responsible for these differences.

Interação mãe-bebê pré-termo e mudança no estado de humor: comparação do Método Mãe-Canguru com visita na Unidade de Terapia Intensiva Neonatal

OBJETIVO: avaliar mudanças nos estados de humor de mães de bebês pré-termo em função do tipo de contato com o seu filho: Método Mãe-Canguru (MMC) e visita ao filho na incubadora da Unidade de Terapia Intensiva Neonatal. MÉTODOS: foi aplicada a Escala Analógica de Humor em 60 mães divididas em 2 grupos: mães que participam do Método Mãe-Canguru (GC) e mães que acompanharam o bebê na incubadora (GI). Os grupos foram pareados em função da idade das mães, número de gestações e tipo de parto. As mães foram avaliadas antes e depois de uma das visitas ao filho na incubadora ou sessão de MMC. RESULTADOS: as mães do GC melhoraram o humor, relatando: sentirem-se mais calmas, fortes, com idéias claras, ágeis, dinâmicas, satisfeitas, tranqüilas, perspicazes, relaxadas, atentas, competentes, alegres e amistosas. As mães do GI não apresentaram melhora no estado de humor em nenhum item, mas pioraram no item "sentindo-se desajeitada". CONCLUSÕES: o Método Mãe-Canguru mostrou-se eficaz na melhora nos estados de humor de mães de bebês pré-termo, contribuindo assim para a minimização dos efeitos negativos da internação neonatal.

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

OBJECTIVE

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

STUDY DESIGN

Literature review.

RESULT

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

CONCLUSION

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

Digitally recycled incubators: better economic alternatives to modern systems in low-income countries

The need to maintain a neutral thermal environment is critical to newborn care.

AIM

To investigate reasons for the insufficiency of functional incubators and develop a cost-effective technique for using electronic digital components to recycle obsolete incubators in Nigeria.

METHODS

Following interview of 84 clinicians and administrators in Nigerian hospitals, it was identified that inadequate funding was the main reason for lack of functional incubators. Two groups of incubator units were then created and their performance compared. Sixteen units of modern (group A) and 19 units of obsolete (group B) incubators were obtained from six hospitals. An assembly design applying independent generic components for recycling systems was specified and produced. These were sourced through the internet at competitive cost and fitted into the reconstructed panels of the obsolete systems. The functional performance of each recycled system was rigorously monitored for 6 months and graded using ten performance indices. The same indices were used to quantify group A systems.

RESULTS

The performance of the recycled incubators (group B) was found to be similar to those of modern incubators. Group B's cost index was found to be 25% of that of group A's.

CONCLUSION

Appropriate incubator recycling is a cost-effective method of re-equipping hospitals in low-income countries.

Breast and infant temperatures with twins during shared Kangaroo Care

Kangaroo Care has been shown to keep a singleton preterm infant warm by body heat generated in maternal breasts that is conducted to the infant. No studies have examined whether twins simultaneously receiving Kangaroo Care, called Shared Kangaroo Care, are sufficiently warm and how the breasts respond to twin presence. Two case studies were done to determine the temperatures of twins being simultaneously kangarooed and the temperatures of maternal breasts during Shared Kangaroo Care. Two sets of premature twins were held in Shared Kangaroo Care for 1.5 hours. Infant temperatures were recorded from incubators; breast temperatures were recorded from thermistors. Infant temperatures remained warm and increased during Kangaroo Care, and each breast appeared to respond to the thermal needs of the infant on that breast. Physiological explanations for thermal synchrony exist. These data suggest that twins can be simultaneously held in Kangaroo Care without thermal compromise because each breast responds individually to the infant's thermal needs.