Skin-to-skin contact in the delivery room for very preterm infants: a randomised clinical trial

Safety of Skin-to-Skin Contact with Umbilical Venous Catheter in Preterm Infants: A Prospective Study

OBJECTIVE

 For many health care providers, an umbilical venous catheter (UVC) may be a contraindication for skin-to-skin contact (SSC). Our aim was to compare the frequency of adverse events between preterm infants who were on SSC with UVC and those who remained in an incubator.

STUDY DESIGN

 Prospective observational study in newborns less than 35 weeks gestation. UVC-related adverse events were compared between neonates who performed SSC and those who did not. The incidence of catheter-related displacement, leak, loss, hemorrhage, malfunction, and bloodstream infection was studied.

RESULTS

 From 226 patients, 171 performed SSC with UVC. Their first contact was earlier than in those who remained in an incubator (SSC-UVC, 29 hours [interquartile range (IQR): 21-53] vs. no SSC-UVC, 132 hours [IQR: 96-188]; p < 0.001). Both groups were similar in gestational age (SSC-UVC, 30 weeks vs. no SSC-UVC, 30.3 weeks; p = 0.331) and birth weight (SSC-UVC, 1,285 g vs. no SSC-UVC, 1,355 g; p = 0.2). Studied complications were not more frequent in patients who performed SSC. In fact, although it was not statistically significant, a lower overall incidence of adverse events (SSC-UVC, 13.5% vs. no SSC-UVC, 20%; p = 0.237) and catheter-related bloodstream infection (SSC-UVC, 4.7% vs. no SSC-UVC, 10.9%; p = 0.111) was observed in this group.

CONCLUSION

 SSC with a UVC is a safe procedure and there are no more complications in newborns who perform SSC compared to those who remain in the incubator. Due to its demonstrated benefits, SSC should be promoted in premature newborns regardless of the presence of a UVC.

KEY POINTS

· SSC in preterm infants with UVCs is safe.. · Early SSC does not increase UVC-related bloodstream infection.. · Early SSC should be promoted in stable patients regardless of the presence of a UVC..

Neonatal skin health and associated dermatological conditions

PURPOSE OF REVIEW

This review describes recent developments in neonatal skincare management and situates these findings within the preexisting literature on neonatal dermatology.

RECENT FINDINGS

The studies included in this review expand research methods evaluating skincare management to different contexts across the world. Several studies explore the roles of emollient therapy, disinfection, and skin-to-skin contact on improving neonates' long-term health outcomes. Recent findings also assess the impact of neonatal interventions on atopic dermatitis risk later in life as well as epidemiological and microbiome variables that may predict this risk. Additionally, updates on various dermatological conditions unique to neonates are discussed in further detail.

SUMMARY

Neonatal skincare management differs in notable ways from that of other age groups. The presentation of dermatologic diseases as well as the rare conditions that affect neonates make their clinical management unique. The recent literature on neonatal dermatology can help inform clinicians regarding important considerations in treating their neonatal population.

Early skin-to-skin contact and the risk of intraventricular haemorrhage and sepsis in preterm infants

AIM

This study aimed to investigate the risks of intraventricular haemorrhage (IVH) or sepsis in extremely and very preterm infants exposed to early skin-to-skin contact (SSC).

METHODS

Data from the Swedish Neonatal Quality Register from 2015 to 2021 were extracted to compare the proportions of infants exposed and not exposed to SSC on day 0 and/or 1 in life that developed IVH or sepsis.

RESULTS

A total of 2514 infants, 1005 extremely preterm and 1509 very preterm, were included. This amounted to 69% of all extremely and very preterm infants born during the study period. The proportion of infants with IVH exposed and not exposed to early SSC was 11% and 27%, an adjusted odds ratio (aOR) of 0.67 (95%CI 0.52-0.86, p = 0.002). The proportion of infants with sepsis exposed and not exposed to early SSC was 16% and 30%, an aOR of 0.94 (95%CI 0.75-1.2, p = 0.60). For extremely preterm infants, the proportion with sepsis when exposed and not exposed to early SSC was 29% and 44%, an aOR of 0.65 (95%CI 0.46-0.92, p = 0.015).

CONCLUSION

In the current setting, the risk of IVH or sepsis is not increased when an extremely or very preterm infant is exposed to early SSC.

New policies on skin-to-skin contact warrant an oxytocin-based perspective on perinatal health care

Background

In 2023, the World Health Organization (WHO) published a Global Position Paper on Kangaroo Mother Care (KMC), which is applicable to all countries worldwide: from the moment of birth, every "small and sick" newborn should remain with mother in immediate and continuous skin-to-skin contact (SSC), receiving all required clinical care in that place. This was prompted by the startling results of a randomized controlled trial published in 2021: in which 1,609 infants receiving immediate SSC were compared with 1,602 controls that were separated from their mothers but otherwise received identical conventional state-of-the-art care. The intervention infants showed a 25% reduction in mortality after 28 days.

New perspectives

The new WHO guidelines are a significant change from earlier guidance and common clinical practice. The author presents that separating mothers and babies is assumed to be "normal" (a paradigm) but actually puts newborns at increased risk for morbidity and mortality. The author presents arguments and ethical perspectives for a new perspective on what is "normal," keeping newborns with their mothers is the infant's physiological expectation and critical requirement for healthy development. The author reviews the scientific rationale for changing the paradigm, based on synchronous interactions of oxytocin on both mother and infant. This follows a critique of the new policies that highlights the role of immediate SSC.

Actionable recommendations

This critique strengthens the case for implementing the WHO guidelines on KMC for small and sick babies. System changes will be necessary in both obstetric and neonatal settings to ensure seamless perinatal care. Based on the role of oxytocin, the author identifies that many current routine care practices may actually contribute to stress and increased vulnerability to the newborn. WHO has actionable recommendations about family involvement and presence in newborn intensive care units.

Discussion

The concepts of resilience and vulnerability have specific definitions well known in perinatal care: the key outcome of care should be resilience rather than merely the absence of vulnerability. Newborns in all settings and contexts need us to re-evaluate our paradigms and adopt and implement the new WHO guidelines on KMC in perinatal care.

Adapting power calculations to include a superiority margin: what are the implications?

This paper examines the application of super-superiority margins in study power calculations. Unlike traditional power calculations, which primarily aim to reject the null hypothesis by any margin, a super-superiority margin establishes a clinically significant threshold. Despite potential benefits, this approach, akin to a non-inferiority calculation but in an opposing direction, is rarely used. Implementing a super-superiority margin separates the notion of the likely difference between two groups (the effect size) from the minimum clinically significant difference, without which inconsistent positions could be held. However, these are often used interchangeably. In an audit of 30 recent randomized controlled trial power calculations, four studies utilized the minimal acceptable difference, and nine utilized the expected difference. In the other studies, this was unclarified. In the post hoc scenario, this approach can shed light on the value of undertaking further studies, which is not apparent from the standard power calculation. The acceptance and rejection of the alternate hypothesis for super-superiority, non-inferiority, equivalence, and standard superiority studies have been compared. When a fixed minimal acceptable difference is applied, a study result will be in one of seven logical positions with regards to the simultaneous application of these hypotheses. The trend for increased trial size and the mirror approach of non-inferiority studies implies that newer interventions may be becoming less effective. Powering for superiority could counter this and ensure that a pre-trial evaluation of clinical significance has taken place, which is necessary to confirm that interventions are beneficial.

Mother-newborn couplet care: Nordic country experiences of organization, models and practice

Mother-Newborn Couplet Care is a concept and is defined as the provision of care for a sick or preterm newborn in close proximity to and coupled with the care for the mother from the birth of the infant and for as long as the mother needs hospital care. This concept of care requires system change in both obstetrics and pediatrics in terms of the planning and organization of care, equipment and design of units. Accordingly, strong leadership setting clear goals and emphasizing a culture of cohesive care, supported by targeted education and training is crucial to ensure high-quality care of all mother-newborn dyads without separation. We describe various organizational models of Mother-Newborn Couplet Care used in Sweden and Finland and implementation processes. We envision a future where newborns and mothers are always together, irrespective of medical needs, and form an inseparable center around which healthcare services and providers are organized.