Early skin-to-skin contact or incubator for very preterm infants: study protocol for a randomized controlled trial

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

OBJECTIVE

Evaluating safety, feasibility and effects on physiological parameters of skin-to-skin contact (SSC) from birth between mothers and very preterm infants in a high-income setting.

DESIGN

Open-label randomised controlled trial.

SETTING

Three Norwegian neonatal units.

PATIENTS

Preterm infants at gestational age (GA) 28⁰-31⁶ weeks and birth weight >1000g delivered vaginally or by caesarean section (C-section).

INTERVENTION

Two hours of early SSC between the mother and the infant compared to standard care (SC) where the infant is separated from the mother and transferred to the neonatal unit in an incubator.

RESULTS

108 infants (63% male, 57% C-section, mean (SD) GA 30.3 weeks (1.3) and birth weight 1437 g (260)) were included. Median (IQR) age at randomisation was 23 min (17-30). During the first 2 hours after randomisation, 4% (2 of 51) and 7% (4 of 57) were hypothermic (<36.0°C) in the SSC and SC group, respectively (p=0.68, OR 0.5, 95% CI 0.1 to 3.1). Significantly fewer infants in the SSC group had hyperthermia (>37.5°C) (26% (13 of 57) vs 47% (27 of 51), respectively, p=0.02, OR 0.4, 95% CI 0.2 to 0.9). No infant needed mechanical ventilation within the first 2 hours. Median (IQR) duration of SSC was 120 (80-120) min in the intervention group. There was no difference in heart rate, respiratory rate and oxygen saturation between groups during the first 24 hours.

CONCLUSION

This study from a high-income setting confirmed that SSC from birth for very preterm infants was safe and feasible. Physiological parameters were not affected by the intervention. The long-term effects on neurodevelopment, maternal-infant bonding and maternal mental health will be collected.

TRIAL REGISTRATION NUMBER

NCT02024854.

Early skin-to-skin contact and risk of late-onset-sepsis in very and extremely preterm infants

BACKGROUND

To evaluate the association between exposure to early skin-to-skin contact (SSC) and incidence of late-onset sepsis (LOS) in extremely and very preterm infants.

METHODS

Observational study using the national population-based EPIPAGE-2 cohort in 2011. A propensity score for SSC exposure was used to match infants with and without exposure to SSC before day 4 of life and binomial log regression used to estimate risk ratios and CIs in the matched cohort. The primary outcome was at least one episode of LOS during hospitalization. Secondary outcomes were the occurrence of any late-onset neonatal infection (LONI), LOS with Staphylococcus or Staphylococcus aureus, incidence of LOS and LONI per 1000 central venous catheter days.

RESULTS

Among the 3422 included infants, 919 were exposed to early SSC. The risk ratio (RR) for LOS was 0.86 (95% CI, 0.67-1.10), for LONI was 1.00 (95% CI, 0.83-1.21), and for LOS with Coagulase-negative Staphylococcus or Staphylococcus aureus infection was 0.91 (95% CI, 0.68-1.21) and 0.77 (95% CI, 0.31-1.87). The incidence RR for LOS per-catheter day was 0.87 (95% CI, 0.64-1.18).

CONCLUSION

Early SSC exposure was not associated with LOS or LONI risk. Thus, their prevention should not be a barrier to a wider use of SSC.

IMPACT

Kangaroo Mother Care decreased neonatal infection rates in middle-income countries. Skin-to-skin contact is beneficial for vulnerable preterm infants but barriers exist to its implementation. In a large population-based study using a propensity score methods, we found that skin-to-skin contact before day 4 of life was not associated with a decreased risk of late-onset-sepsis in very and extremely preterm infants. Early skin-to-skin contact was not associated with an increased risk of any late-onset-neonatal-infection, in particular with staphylococcus. The fear of neonatal infection should not be a barrier to a wider use of early skin-to-skin contact in this population.

Skin-to-skin SDF positioning: The key to intersubjective intimacy between mother and very preterm newborn-A pilot matched-pair case-control study

Background

Skin-to-skin contact (SSC) has been widely studied in NICU and several meta-analyses have looked at its benefits, for both the baby and the parent. However, very few studies have investigated SSC' benefits for communication, in particular in the very-preterm newborn immediately after birth.

Aims

To investigate the immediate benefits of Supported Diagonal Flexion (SDF) positioning during SSC on the quality of mother-very-preterm newborn communication and to examine the coordination of the timing of communicative behaviors, just a few days after birth.

Subjects and study design

Monocentric prospective matched-pair case-control study. Thirty-four mothers and their very preterm infants (27 to 31 + 6 weeks GA, mean age at birth: 30 weeks GA) were assigned to one of the two SSC positioning, either the Vertical Control positioning (n = 17) or the SDF Intervention positioning (n = 17). Mother and newborn were filmed during the first 5 min of their first SSC.

Outcome measures

Infants' states of consciousness according to the Assessment of Preterm Infants' Behavior scale (APIB). Onset and duration of newborns' and mothers' vocalizations and their temporal proximity within a 1-s time-window.

Results

In comparison with the Vertical group, very preterm newborns in the SDF Intervention Group spent less time in a drowsy state and more in deep sleep. At 3.5 days of life, newborns' vocal production in SSC did not differ significantly between the two groups. Mothers offered a denser vocal envelope in the SDF group than in the Vertical group and their vocalizations were on average significantly longer. Moreover, in a one-second time-frame, temporal proximity of mother-very preterm newborn behaviors was greater in the SDF Intervention Group.

Conclusion

Although conducted on a limited number of dyads, our study shows that SDF positioning fosters mother-very preterm newborn intimate encounter during the very first skin to skin contact after delivery. Our pioneer data sheds light on the way a mother and her very preterm vocally meet, and constitutes a pilot step in the exploration of innate intersubjectivity in the context of very preterm birth.

Postpartum Experiences of Early Skin-to-Skin Contact and the Traditional Separation Approach After a Very Preterm Birth: A Qualitative Study Among Mothers

Traditional care immediately after very preterm birth separates the mother and child by the transfer of the infant to the neonatal intensive care unit. A nonseparation approach is currently being considered, allowing early skin-to-skin contact in the delivery room/postoperative care unit. This study aimed to explore mothers’ experiences of early skin-to-skin contact and traditional care. A qualitative study using individual semi-structured interviews with five mothers from each of the two groups was conducted. Content analysis revealed that both groups’ experiences were characterized by (i) mothers’ need to be affirmed of their infants’ vitality, (ii) bonding challenges, and (iii) benefits of skin-to-skin contact. We suggest that early skin-to-skin contact after very preterm births is crucial for the bonding process and mothers’ feelings of safety and well-being. When early skin-to-skin contact is infeasible, our findings reveal the significance of photos, information, and the father’s presence at the time of postpartum separation.

A Quality Improvement Project to Increase Frequency of Skin-to-Skin Contact for Extreme Low-Birth-Weight Infants in the Neonatal Intensive Care Unit

Benefits of skin-to-skin contact (SSC) are documented but often delayed in the extremely preterm population due to medical complexity and staff misconceptions about safety. This quality improvement initiative was designed to increase SSC utilization among infants born before 29 weeks' gestation regardless of respiratory support by addressing nursing barriers inhibiting SSC. A pre-/postsurvey evaluated comfort level performing and perceived barriers to SSC utilization. Implementation consisted of an updated unit-specific SSC protocol and tailored education specific to identified barriers. Evaluation included SSC rates and maternal human milk usage in the first 30 days of life. In total, 81 patients (22-28 weeks, 370-1410 g) were included. SSC rates ranged from 3.3% to 17.7% at baseline and increased to 33.2% to 39.1% postintervention. Maternal human milk utilization increased above target (≥75%) postintervention for days 7 and 14, but declined towards baseline on days 21 and 30. A statistically significant increase was observed in nursing comfort level when performing SSC for intubated infants as well as infants with a peripherally inserted central catheter or umbilical venous catheter. SSC rates increased with infants younger than 29 weeks requiring intubation and central line management, possibly as a result of greater nursing comfort surrounding with SSC.

Delivery room cuddles for extremely preterm babies and parents: concept, practice, safety, parental feedback

Aim

Following extreme preterm birth, there has traditionally been felt an imperative to rush baby to the neonatal unit for ongoing intensive care. Immediate needs of parents to bond with their babies through direct early physical contact have often been overlooked; many weeks can pass before parents get to hold their babies for the first time. Recognition of the importance of early contact is growing. We aimed to review the safety and value of routinely practising delivery room cuddles for extremely preterm babies.

Methods

We reviewed delivery room cuddles in babies born <27 weeks’ gestation in our centre between 2006 and 2017 via case‐control. We also conducted a questionnaire survey of mothers who experienced a delivery room cuddle to gain their feedback and perspectives.

Results

We found no difference in age or temperatures on neonatal unit admission. There was no case of inadvertent extubation associated with cuddles. Parental feedback was very positive.

Conclusion

With appropriate safeguards, delivery room cuddles are feasible and achievable for extremely preterm babies irrespective of birth gestation. Facilitation of the cuddle is an early and very important family‐centred care practice which seems much appreciated by parents and which may improve bonding, lactation, and maternal mental health.

Delivery room skin-to-skin contact in preterm infants affects long-term expression of stress response genes

Premature birth is a traumatic event that puts mother and child at risk for subsequent psychopathology. Skin-to-skin contact in the form of intermittent kangaroo mother care has been shown to positively affect the infant's stress response and cognitive development, but underlying mechanisms remain unclear. Moreover, first skin-to-skin contact is usually delayed for days after birth. In the delivery room skin-to-skin study (DR-SSC), a prospective randomized controlled trial conducted from 2/2012 to 7/2015, we set out to assess the effect of delivery room skin-to-skin contact on the infant's mRNA expression of six key molecules involved in stress response and neurobehavioral development at hospital discharge. 88 firstborn, singleton preterm infants (born at 25-32 weeks of gestational age) were included. In the delivery room after initial stabilization, infants were randomized to either 60 min of skin-to-skin or 5 min of visual contact with their mother. In this explorative add-on study on the original DR-SSC study, we determined the expression of six important stress response genes (CRHR1 and CRHR2, AVP, NR3C1, HTR2A, and SLC6A4) in peripheral white blood cells of infants during routine blood sampling upon hospital discharge (corrected gestational age of 40 weeks). Infants were followed up to six months corrected age. Relative mRNA expression of the corticotropin releasing hormone receptor 2 (CRH R2), the glucocorticoid receptor gene (NR3C1), and the serotonin transporter gene (SLC6A4) was significantly reduced in the delivery room SSC infants. Additionally, gene expression of CRH R2 showed a correlation with HPA axis reactivity and parameters of mother-child interaction at six months corrected age. Our results highlight the importance of delivery room mother-child skin-to-skin contact and underline the urgent need for in-depth studies on the underlying molecular mechanisms.

Delivery room skin-to-skin contact for preterm infants-A randomized clinical trial

AIM

To investigate the effects of 60 minutes delivery room skin-to-skin contact (DR-SSC) compared with 5 minutes visual contact (VC) on mother-child interaction (MCI), salivary cortisol, maternal depression, stress and bonding at 6 months corrected age.

METHODS

A single-centre randomized controlled trial conducted in a German level III NICU. Eighty-eight preterm infants (25-32 weeks of gestational age) were randomized after initial stabilization to either 60 minutes DR-SSC or 5 minutes VC. Forty-five infants were allocated to DR-SSC, 43 to VC.

RESULTS

Delivery room skin-to-skin contact dyads showed a higher quantity of maternal motoric (18 vs 15, P = .030), infant's vocal (7 vs 5, P = .044) and motoric (20 vs 15, P = .032) responses. Moreover, the combined score of maternal and infant responsive behaviour was higher (86 vs 71, P = .041) in DR-SSC dyads. DR-SSC mothers had lower risk of both, early postpartum depression (15% vs 45%, P = .003) and impaired bonding (Score 3 vs 5, P = .031).

CONCLUSION

In addition to regular intermittent kangaroo mother care, DR-SSC promotes MCI and decreases risk of maternal depression and bonding problems. Thus, DR-SSC may have positive effects on preterm development.

Fostering mother-very preterm infant communication during skin-to-skin contact through a modified positioning

BACKGROUND

Skin-to-skin contact (SSC) has been widely studied in NICU and several meta-analyses have looked at its benefits both for the baby and the parent. Very few studies however have investigated benefit for communication.

AIMS

Investigate the immediate benefits of Supported Diagonal Flexion (SDF) positioning during SSC on the quality of mother - very-preterm infant communication and to gain insight into how mothers' and very-preterm infants' communicative behaviours are coordinated in time just a few days after birth.

SUBJECTS AND STUDY DESIGN

Monocentric prospective matched-pair case-control study. Thirty-four mothers and their very preterm infants (27 to 31 + 6 weeks GA; mean age at birth 30: weeks GA) were assigned to one of the two SSC positioning, either the Vertical Control (n = 17) or the SDF Intervention positioning (n = 17). Mother and infant were filmed during the first 5 min of SSC, 15 days after the very first SSC (i.e. 18 days after very premature birth, i.e. on average 32.4 weeks GA).

OUTCOME MEASURES

Infants' state of consciousness according to the Assessment of Preterm Infants' Behavior scale. Onset and duration of infants' and mothers' smiles, gazes and vocalizations, and their temporal proximity inside a 1-sec time-window.

RESULTS

In the SDF Intervention Group, very preterm infants vocalized three times more and mothers vocalized, gazed at their baby's face, and smiled more than in the Vertical Control Group. Moreover, in a one-second time-frame, temporal proximity of mother-infant behaviours was greater in the SDF Intervention Group.

CONCLUSIONS

Our study shows that SDF positioning creates more opportunities for mother-infant communication during SSC. SDF positioning fosters a greater multimodal temporal proximity thus supporting a more qualitative mother-infant communication.

Delivery room handling of the newborn

For newly born babies, especially those in need of intervention at birth, actions taken during the first minute after birth, the so-called "Golden Minute", can have important implications for long-term outcomes. Both delivery room handling, including identification of maternal and infant risk factors and provision of effective resuscitation interventions, and antenatal care decisions regarding antenatal steroid administration and mode of delivery, are important and can affect outcomes. Anticipating risk factors for neonates at high risk of requiring resuscitation can decrease time to resuscitation and improve the prognosis. Following a review of maternal and fetal risk factors affecting newborn resuscitation, we summarize the current recommendations for delivery room handling of the newborn. This includes recommendations and rationale for the use of delayed cord clamping and cord milking, heart rate assessment [including the use of electrocardiogram (ECG) electrodes in the delivery room], role of suctioning in newborn resuscitation, and the impact of various ventilatory modes. Oxygenation should be monitored by pulse oximetry. Effects of oxygen and surfactant on subsequent pulmonary outcomes, and recommendations for provisions of appropriate thermoregulatory support are discussed. Regular teaching of delivery room handling should be mandatory.