Associations Between Nurse-Guided Variables and Plasma Oxytocin Trajectories in Premature Infants During Initial Hospitalization

Quality Improvement Initiative in the NICU for Improved Practice of Cuff Blood Pressure Measurements

BACKGROUND

Extreme preterm infants face lengthy hospitalizations and are often subjected to painful stimuli. These stimuli may be related to routine caregiving that may negatively impact long-term developmental outcomes. Frequently obtained cuff blood pressure (BP) measurements are an example of a potentially noxious stimulus to preterm infants that may have a cumulating impact on development.

PURPOSE

The primary aim was to explore the frequency of cuff BP measurements obtained in hemodynamically stable extreme preterm infants in the neonatal intensive care unit (NICU). Our secondary aim was to reduce the number of cuff BP measurements obtained in hemodynamically stable extreme preterm infants in the NICU.

METHODS

Quality improvement methodologies per the Institute for Healthcare Improvement were used combined with a multidisciplinary approach. Participants were infants born less than 27 weeks of gestation and discharged home. The baseline period was 2015 through Q2-2018 and the intervention period was Q3-2018 through Q1-2020. The electronic medical record was used to collect data and Minitab Statistical Software was used for data analysis.

FINDINGS/RESULTS

A baseline of 5.0% of eligible patients received the desired number of cuff BP measurements and increased to 63.2% after the intervention period.

IMPLICATIONS FOR PRACTICE

Findings demonstrate that using quality improvement methodology can improve clinical care. Findings suggest the feasibility and safety of reducing the number of cuff BP measurements obtained on hemodynamically stable infants in the NICU.

IMPLICATIONS FOR RESEARCH

Future endeavors should aim to reduce the quantity of painful stimuli in the NICU. Long-term developmental outcomes should be correlated in these patients.

Skin-to-skin contact to support preterm infants and reduce NICU-related stress

OBJECTIVE

Hospitalization in the neonatal intensive care unit (NICU) with numerous painful medical interventions, being separated from parents, leads to the high risk of chronic stress for preterm infants. Today, many NICUs use more appropriate developmental care and pain management, but the early and long-term outcomes of stress in these vulnerable infants require searching for more stress-reducing interventions in neonatal care. The objective of the study was to investigate how skin-to-skin contact (SSC) can influence the biologic stress levels in preterm infants in the NICU by assessing cortisol and oxytocin levels.

PARTICIPANTS AND METHODS

The study included 71 preterm infants with gestational age less than 34 + 0/7 weeks who were recruited from level III NICU. The overall design was a baseline-response design. Saliva and urine were collected before (baseline) and after skin-to-skin contact to measure salivary cortisol and urinary oxytocin by enzyme immunoassay method.

RESULTS

The infants' baseline hormonal status was represented by the following indicators: the level of salivary cortisol was 0.402 [0.227; 1,271] μg/dl, urinary oxytocin 48.88 [32.97; 88.11] pg/ml. There was a decrease in salivary cortisol levels to 0.157 [0.088; 0.351] μg/dl compared to baseline (p ˂ 0.001) with a simultaneous increase of the urinary oxytocin level -73.59 [45.18; 108.8] pg/ml (p = 0.028) in response to SSC.

CONCLUSION

Preterm infants in the NICU experience significant stress, characterized by hormonal imbalance: an increased level of the stress hormone cortisol and a decreased level of the anti-stress hormone oxytocin. Skin-to-skin contact helps to ameliorate the hormonal stress in preterm infants by activating the oxytocin release with simultaneous reduction of cortisol secretion.

A Systematic Review of the Effects of Skin-to-Skin Contact on Biomarkers of Stress in Preterm Infants and Parents

BACKGROUND

Premature infants and their parents experience significant stress related to separation and lifesaving procedures. While evidence suggests that skin-to-skin contact (SSC) is a stress-reducing intervention for both neonates and parents, the mechanisms that underlie its efficacy are not well understood.

OBJECTIVE

Purpose of this systematic review is to summarize the current state of knowledge on changes in biomarkers (ie, oxytocin [OT], cortisol, hypoxanthine, xanthine, uric acid, and allantoin), associated with SSC in premature infants and parents, that may reflect physiologic responses to stress.

METHODS

A comprehensive literature search was conducted from 1990 to 2020. Studies were selected using prespecified inclusion and exclusion criteria.

RESULTS

Of the 175 studies identified, only 19 are included in this review. Ten studies evaluated only infants, 2 evaluated only parents, and 7 evaluated for changes in biomarkers in both infants and parents. Cortisol was the most common biomarker evaluated. While changes in infants' cortisol levels were highly variable, in 55% of the parent studies, parent cortisol levels decreased following SSC. In both parents and infants, OT levels decreased following SSC. Only 1 study found that allantoin levels were significantly lower in infants who received SSC.

IMPLICATIONS FOR PRACTICE AND RESEARCH

While evidence suggests the numerous benefits of SSC, additional research is needed to identify the optimal biomarker to determine the mechanisms that underlie these effects. The use of novel biomarkers (eg, gene expression changes microbiome) may provide new insights into the mechanisms that underlie the efficacy of SSC.Video Abstract available at:https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=48.

Application of a Risk Management Framework to Parent Sleep During Skin-to-Skin Care in the NICU

As NICU staff work to increase the frequency, duration, and comfort of skin-to-skin care (SSC) sessions, barriers to implementation are frequently encountered. Safety concerns are often raised when parents fall asleep during SSC intentionally or unintentionally. We present a risk management framework that we use in clinical practice to address risk related to parent sleep during SSC. Our approach is based on the steps of the Risk Management Life Cycle, which include the following: establish context, identify risk, analyze risk, respond to risk, and monitor and adapt response to risk. Clinicians may use this framework in clinical practice to manage risks related to prolonged SSC, specifically when parents relax and fall asleep during SSC.

Changes in Clinical Care of the Newborn During COVID-19 Pandemic: From the Womb to First Newborn Visit

COVID-19 has afflicted the health of children and women across all age groups. Since the outbreak of the pandemic in December 2019, various epidemiologic, immunologic, clinical, and pharmaceutical studies have been conducted to understand its infectious characteristics, pathogenesis, and clinical profile. COVID-19 affects pregnant women more seriously than nonpregnant women, endangering the health of the newborn. Changes have been implemented to guidelines for antenatal care of pregnant women, delivery, and newborn care. We highlight the current trends of clinical care in pregnant women and newborns during the COVID-19 pandemic.

Establishing a Foundation for Optimal Feeding Outcomes in the NICU

Many infants in the NICU experience difficulties with oral feeding, which contribute to prolonged length of stay. Oral feeding is a complex task involving sensorimotor functioning of the face, mouth, and larynx, as well as coordination of sucking, swallowing, and breathing. The care provided in the NICU starting at birth sets the stage for future oral feeding. The purpose of this article is to describe strategies that will establish a positive foundation to support optimal oral feeding. Nurses can use these strategies to protect newborns from noxious stimuli and promote positive auditory, tactile, gustatory, and olfactory experiences to optimize neurodevelopment for the complex task of feeding.

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.

Reducing toxic stress in the neonatal intensive care unit to improve infant outcomes

In 2011, the American Academy of Pediatrics (AAP) published a technical report on the lifelong effects of early toxic stress on human development, and included a new framework for promoting pediatric health: the Ecobiodevelopmental Framework for Early Childhood Policies and Programs. We believe that hospitalization is a specific form of toxic stress for the neonatal patient, and that toxic stress must be addressed by the nursing profession in order to substantially improve outcomes for the critically ill neonate. Approximately 4% of normal birthweight newborns and 85% of low birthweight newborns are hospitalized each year in the highly technological neonatal intensive care unit (NICU). Neonates are exposed to roughly 70 stressful procedures a day during hospitalization, which can permanently and negatively alter the infant's developing brain. Neurologic deficits can be partly attributed to the frequent, toxic, and cumulative exposure to stressors during NICU hospitalization. However, the AAP report does not provide specific action steps necessary to address toxic stress in the NICU and realize the new vision for pediatric health care outlined therein. Therefore, this paper applies the concepts and vision laid out in the AAP report to the care of the hospitalized neonate and provides action steps for true transformative change in neonatal intensive care. We review how the environment of the NICU is a significant source of toxic stress for hospitalized infants. We provide recommendations for caregiving practices that could significantly buffer the toxic stress experienced by hospitalized infants. We also identify areas of research inquiry that are needed to address gaps in nursing knowledge and to propel nursing science forward. Finally, we advocate for several public policies that are not fully addressed in the AAP technical report, but are vital to the health and development of all newborns.

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

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