A double-blind randomized controlled pilot trial examining the safety and efficacy of therapeutic touch in premature infants

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

BACKGROUND

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

OBJECTIVES

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

ELIGIBILITY CRITERIA

Human neonates ≤1 month of corrected age.

SOURCES OF EVIDENCE

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

CHARTING METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

A Concept Analysis on the Use of Yakson in the NICU

In the NICU context, Yakson is defined as a mother's gentle, nurturing, and soothing touch that is meant to comfort her newborn and results in the newborn's physically relaxed and emotionally stable condition, the mother's satisfaction and confidence, and stronger mother-infant interaction and attachment. Although this concept analysis is based on Korean culture, the understanding of Yakson can help nurses promote this feasible practice to enhance mother-infant interaction and attachment in the NICU.

Nontouch biofield therapy: a systematic review of human randomized controlled trials reporting use of only nonphysical contact treatment

OBJECTIVE AND CONTEXT: This review was designed to assess the quality and review the outcomes of randomized controlled trials (RCTs) of biofield therapies (external qigong, Healing Touch, Johrei, Reiki, and Therapeutic Touch) that report using only nonphysical touch forms of treatment. RCTs of nonphysical contact biofield therapies have the potential to contribute to an evidence base for health-promoting effects mediated through mechanisms outside the present understanding of biomedicine.

METHODS

Articles meeting inclusion criteria were identified from database and reference list searches and evaluated for a range of reporting and design items. Data were extracted to determine the range of protocol parameters and treatment outcomes. The final set of included RCTs were evaluated via a modified 5-item Jadad scale as well as by a set of 20 criteria that included items relevant to the early-phase nature of the trials and to the examination of nonphysical touch biofield therapy interventions.

RESULTS

Of 90 RCTs that assessed effectiveness of a biofield therapy in humans, 28 trials involving 1775 participants met additional inclusion criteria (most importantly a clearly reported use of only nonphysical contact treatment). The research designs of these 28 trials revealed marked heterogeneity in regard to condition treated, number and duration of treatments, nature of the control/comparison group, and outcome measures. Finally, 10 trials were excluded on the basis of low quality assessment scores. Twelve of the remaining 18 trials (7 Therapeutic Touch, 3 external qigong, 1 Reiki, and 1 Healing Touch) reported at least one primary outcome with statistically significant beneficial treatment outcomes.

CONCLUSIONS

The pilot study nature of essentially all the identified nonphysical contact biofield therapy RCTs, as reflected by low sample sizes alone, precludes drawing robust conclusions. Given this perspective, the finding that two thirds of the higher-scoring trials demonstrated at least partial effectiveness favors a continued research effort, especially in light of the translational value of biofield clinical trials for studies exploring the nature and physiologic basis of biofield healing.

A randomized-controlled trial pilot study examining the neurodevelopmental effects of a 5-week M Technique intervention on very preterm infants

PURPOSE

To systematically test the cumulative effect of the M Technique on infant neurodevelopment in hospitalized very preterm infants.

DESIGN

A pilot randomized controlled trial (RCT).

SUBJECTS

Twenty very preterm infants (<30 weeks gestation with average birth weights <1000 g) were randomly assigned to nontreatment or treatment groups. The study period began once the infants reached 30 weeks postmenstrual age (PMA).

METHODS

Each infant received standard neonatal intensive unit (NICU) care or standard NICU care plus a 7-minute M Technique session, 6 times per week for 5 weeks. Neurobehavioral development (using the NICU Network Neurobehavioral Scale [NNNS]) and growth velocity (difference in infant weight at the beginning and end of protocol) were compared between the 2 groups. Physiologic parameters (heart rate, respiratory rate, and oxygen saturations) and infant behavioral states were measured 5 minutes before, during, and up to 10 minutes postintervention continuously on all infants in the treatment group at 3 different gestational time points (30, 32, and 34 weeks PMA) over the 5-week period.

RESULTS

Mann-Whitney U analyses revealed no differences between the 2 groups on all 12 NNNS summary score domains but a difference in growth velocity between the 2 groups (P = 0.005). Repeated-measures analysis of variance revealed significant physiologic differences of mean heart rate, respiratory rate, and SaO2 (F = 41.116, P < 0.0005) and behavioral states (F = 38.564, P < 0.0005) from baseline to 10 minutes after the M Technique intervention across all 3 time points. State scores decreased from baseline (M = 6.11) to post intervention (M = 1.4) at all 3 time points.

CONCLUSIONS

This pilot RCT demonstrates the utility of the M Technique in hospitalized very preterm infants starting at 30 weeks PMA with notable evidence of positive weight, physiological, and behavioral state adaptations. Additional research is needed with a larger, randomized design to determine short- and long-term effects specifically related to neurological outcomes.

Therapeutic touch is not therapeutic for procedural pain in very preterm neonates: a randomized trial

BACKGROUND

Preterm neonates below 30 weeks' gestational age undergo numerous painful procedures. Many management approaches are not appropriate for this population. Therapeutic Touch, an alternative approach based on the theory of energy medicine, has been shown to promote physiological stability in preterm neonates and reduce pain in some adult studies. The objective was to determine whether Therapeutic Touch is efficacious in decreasing pain in preterm neonates.

METHODS

Infants < 30 weeks' gestational age participated in a randomized control trial in 2 level III neonatal intensive care units. All evaluations, analyses, and heel lance procedure were conducted with only the therapist knowing the group assignment. Immediately before and after the heel lance procedure, the therapist performed nontactile Therapeutic Touch (n = 27) with infant behind curtains, leaving the curtained area for the heel lance, performed by another. In the sham condition (n = 28), the therapist stood by the incubator with hands by her side. The Premature Infant Pain Profile was used for pain response and time for heart rate to return to baseline for recovery. Heart rate variability and stress response were secondary outcomes.

RESULTS

There were no group differences in any of the outcomes. Mean Premature Infant Pain Profile scores across 2 minutes of heel lance procedure in 30-second blocks ranged from 7.92 to 8.98 in the Therapeutic Touch group and 7.64 to 8.46 in the sham group.

INTERPRETATION

Therapeutic Touch given immediately before and after heel lance has no comforting effect in preterm neonates. Other effective strategies involving actual touch should be considered.

Pain assessment and measurement in neonates: an updated review

Pain assessment and measurement are the cornerstones of pain management. Pain assessment connotes a comprehensive multidimensional description. Conversely, pain measurement provides a numeric quantitative description of each factor illustrating pain qualities. Pain scales provide a composite score used to guide practice and research. The type of infant pain instrument chosen is a significant factor in guiding pain management practice. The purpose of this review was to summarize current infant pain measures by introducing a conceptual framework for pain measurement. Although more than 40 infant pain instruments exist, many were devised solely for research purposes; several of the newly developed instruments largely overlap with existing instruments. Integration of pain management into daily practice remains problematic. Understanding how each instrument measures infant pain allows clinicians to make better decisions about what instrument to use with which infant and in what circumstances. In addition, novel new measurement techniques need further testing.

Comforting touch in the very preterm hospitalized infant: an integrative review

Infants born prematurely lose the protection of the uterus at a time of fetal development when the brain is growing and organizing exponentially. Environmental factors such as stress in the neonatal intensive care unit (NICU) may play a role in altered brain maturation and neurobehavioral outcomes. Strategies aimed at reducing stress and promoting infant well-being are essential to improve neurologic and behavioral outcomes. Infant massage is a developmentally supported strategy aimed at promoting relaxation. However, despite the well-documented benefits of infant massage, infants born very preterm (≤30 weeks' gestation) are often excluded from these studies, leaving neonatal clinicians and families without guidance in how to provide a stress-reducing supplemental touch. Much of the touch in the NICU is a procedural touch, and infants born very preterm often miss out on comforting touch stimulation. A systematic review of the literature is presented with an aim to explore the research that examines the various comforting touch therapies used on hospitalized NICU infants born very preterm within the first few days of postnatal life. The purpose of this review was to identify appropriate stress-reducing comforting touch techniques for physiologically fragile very preterm infants in order to inform and provide guidance to neonatal clinicians and families.

Application of the M Technique in hospitalized very preterm infants: a feasibility study

PURPOSE

To explore the application of a novel relaxation method (the M Technique) in hospitalized very preterm infants in a level IIIC neonatal intensive care unit.

DESIGN

A feasibility, observational intervention study.

SUBJECTS

Ten very preterm infants were enrolled to receive the treatment intervention. Eligible infants born less than 30 weeks' gestation received the intervention at 30 weeks' postmenstrual age.

METHODS

Based on infant readiness, each infant received the M Technique for 5 minutes. Physiologic parameters (heart rate, respiratory rate, and oxygen saturations), behavioral variables (stress and relaxation cues), and infant behavioral state were measured 5 minutes before, during, and up to 10 minutes after the intervention, continuously.

RESULTS

Descriptive analysis revealed that baseline physiologic, behavioral state, and behavioral cue parameters changed during and after the application of the M Technique. A decrease in heart rate and respiratory rate occurred during the M Technique (P = .006, P > .001 respectively) and a decrease in heart rate occurred at the end of the M Technique session (P = .02). In addition, an increase in SaO2 occurred during and at 5 minutes following the M Technique session (P = .04, P = .02, respectively). State scores decreased from baseline (mean = 5.1; range, 3-9) to after the intervention (mean = 2.0, range 1-4). As the intervention was delivered, more positive than negative behavioral cues were observed throughout, at the end, and after the M Technique session.

CONCLUSION

In this feasibility study, the M Technique can be delivered without adverse effects to very preterm infants who are 30 weeks' postmenstrual age. Additional research is needed with a larger, randomized design to determine short- and long-term effects specifically related to neurologic outcomes.

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.