The effect of skin-to-skin contact (kangaroo care) shortly after birth on the neurobehavioral responses of the term newborn: a randomized, controlled trial

A systematic review and multivariate meta-analysis of the physical and mental health benefits of touch interventions

Receiving touch is of critical importance, as many studies have shown that touch promotes mental and physical well-being. We conducted a pre-registered (PROSPERO: CRD42022304281) systematic review and multilevel meta-analysis encompassing 137 studies in the meta-analysis and 75 additional studies in the systematic review (n = 12,966 individuals, search via Google Scholar, PubMed and Web of Science until 1 October 2022) to identify critical factors moderating touch intervention efficacy. Included studies always featured a touch versus no touch control intervention with diverse health outcomes as dependent variables. Risk of bias was assessed via small study, randomization, sequencing, performance and attrition bias. Touch interventions were especially effective in regulating cortisol levels (Hedges' g = 0.78, 95% confidence interval (CI) 0.24 to 1.31) and increasing weight (0.65, 95% CI 0.37 to 0.94) in newborns as well as in reducing pain (0.69, 95% CI 0.48 to 0.89), feelings of depression (0.59, 95% CI 0.40 to 0.78) and state (0.64, 95% CI 0.44 to 0.84) or trait anxiety (0.59, 95% CI 0.40 to 0.77) for adults. Comparing touch interventions involving objects or robots resulted in similar physical (0.56, 95% CI 0.24 to 0.88 versus 0.51, 95% CI 0.38 to 0.64) but lower mental health benefits (0.34, 95% CI 0.19 to 0.49 versus 0.58, 95% CI 0.43 to 0.73). Adult clinical cohorts profited more strongly in mental health domains compared with healthy individuals (0.63, 95% CI 0.46 to 0.80 versus 0.37, 95% CI 0.20 to 0.55). We found no difference in health benefits in adults when comparing touch applied by a familiar person or a health care professional (0.51, 95% CI 0.29 to 0.73 versus 0.50, 95% CI 0.38 to 0.61), but parental touch was more beneficial in newborns (0.69, 95% CI 0.50 to 0.88 versus 0.39, 95% CI 0.18 to 0.61). Small but significant small study bias and the impossibility to blind experimental conditions need to be considered. Leveraging factors that influence touch intervention efficacy will help maximize the benefits of future interventions and focus research in this field.

A narrative review of research linking non-sexual social touch to sleep quality

This narrative review describes the current state of the literature that has examined associations between non-sexual social touch (i.e., affectionate touch, touch therapies, touch with animals and inanimate objects that mimic social touch) and sleep quality. It also highlights areas for future research to clarify the links and to identify underlying mechanisms. Most existing studies have focussed on and shown positive effects of touch therapies (e.g., massage, therapeutic touch) on sleep quality in clinical populations. Although there are fewer studies examining how other forms of social touch are linked with sleep quality, the existing research provides preliminary evidence supporting affectionate touch (e.g., hugging, skin-to-skin contact) and tactile contact with animals (e.g., dogs) and objects that mimic social touch (e.g., robots, weighted blankets) as predictors of better sleep quality, while touch deprivation and touch aversion are associated with worse sleep quality. Informed by the existing literature, we additionally reviewed potential relational-cognitive (e.g., felt-security) and neurobiological (e.g., oxytocin) mechanisms likely to underlie associations between social touch and sleep quality. Overall, current research supports associations between non-sexual social touch and sleep quality. However, future research is needed to establish these links for specific forms of social touch (and in various populations), to test explanatory mechanisms, and to identify boundary conditions. Understanding associations between non-sexual social touch and sleep quality can inform the development of touch-based interventions to improve sleep quality and health.

Parental holding of infants improves haemodynamics in the cardiac ICU

We performed a single-centre, retrospective study to assess physiologic changes of infants in the cardiac ICU while being held by their parent. Continuous data streaming of vital signs were collected for infants included in the study from January 2021 to March 2022. Demographic and clinical characteristics were collected from the electronic medical record. The physiologic streaming data were analysed using mixed-effects models to account for repeated measures and quantify the effect of parental holding. Comparison analysis was also performed controlling for intubation, pre-operative versus post-operative status, and whether the holding was skin-to-skin or not. Ninety-five patients with complete physiologic data were included in the study. There were no immediate adverse events associated with holding. Heart rate decreased during the response time compared to its baseline value (p = 0.01), and this decrease was more pronounced for the non-intubated and pre-operative patients. The near-infrared spectroscopy-based venous saturation increased overall (p = 0.02) in patients while being held. We conclude that parental holding of infants in the cardiac ICU can be safely accomplished, and the haemodynamic and oximetric profile during the holding is favourable compared to the infants' baseline prior to holding.

Skin-to-skin contact for the prevention of neonatal hypoglycaemia: a systematic review and meta-analysis

BACKGROUND

Skin-to-skin contact between mother and infant after birth is recommended to promote breastfeeding and maternal-infant bonding. However, its impact on the incidence of neonatal hypoglycaemia is unknown. We conducted a systematic review and meta-analysis to assess this.

METHODS

Published randomised control trials (RCTs), quasi-RCTs, non-randomised studies of interventions, cohort, or case-control studies with an intervention of skin-to-skin care compared to other treatment were included without language or date restrictions. The primary outcome was neonatal hypoglycaemia (study-defined). We searched 4 databases and 4 trial registries from inception to May 12th, 2023. Quality of studies was assessed using Cochrane Risk of Bias 1 or Effective Public Health Practice Project Quality Assessment tools. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results were synthesised using RevMan 5.4.1 or STATA and analysed using random-effects meta-analyses where possible, otherwise with direction of findings tables. This review was registered prospectively on PROSPERO (CRD42022328322).

RESULTS

This review included 84,900 participants in 108 studies, comprising 65 RCTs, 16 quasi-RCTs, seven non-randomised studies of intervention, eight prospective cohort studies, nine retrospective cohort studies and three case-control studies. Evidence suggests skin-to-skin contact may result in a large reduction in the incidence of neonatal hypoglycaemia (7 RCTs/quasi-RCTs, 922 infants, RR 0.29 (0.13, 0.66), p < 0.0001, I2 = 47%). Skin-to-skin contact may reduce the incidence of admission to special care or neonatal intensive care nurseries for hypoglycaemia (1 observational study, 816 infants, OR 0.50 (0.25-1.00), p = 0.050), but the evidence is very uncertain. Skin-to-skin contact may reduce duration of initial hospital stay after birth (31 RCTs, 3437 infants, MD -2.37 (-3.66, -1.08) days, p = 0.0003, I2 = 90%, p for Egger's test = 0.02), and increase exclusive breastmilk feeding from birth to discharge (1 observational study, 1250 infants, RR 4.30 (3.19, 5.81), p < 0.0001), but the evidence is very uncertain.

CONCLUSION

Skin-to-skin contact may lead to a large reduction in the incidence of neonatal hypoglycaemia. This, along with other established benefits, supports the practice of skin-to-skin contact for all infants and especially those at risk of hypoglycaemia.

Effects of social and sensory deprivation in newborns: A lesson from the Covid-19 experience

BACKGROUND

Infancy is a complex period of human life, in which environmental experiences have a fundamental role for neurodevelopment. Although conditions of social and sensory deprivation are uncommon in high income countries, the Covid-19 pandemic abruptly modified this condition, by depriving people of their social stimuli of daily life.

AIM

To understand the impact of this deprivation on infants' behaviour, we investigated the short-term effects of isolation and use of individual protective systems by mothers during the first two weeks of life.

METHODS

The study included 11 mother-infant dyads with mothers tested positive to SARS-CoV-2 at the time of delivery (Covid group) and 11 dyads with a SARS-CoV-2 negative mother as controls. Neurobehavioral, visual, and sensory processing assessments were performed from birth to 3 months of age.

RESULTS

Findings showed the effect of deprivation on some neurobehavioral abilities of infants in the Covid group; in addition, differences in sensory maturation trends were observed, although they tended to gradually decrease until disappearance at 3 months of age.

CONCLUSION

These findings suggest the significant effects of early sensory and social deprivation during the first two weeks of life, but also provide several insights on the ability of the brain to restore its aptitudes by deleting or reducing the effects of early deprivation before the critical periods' closure.

Early Interventions to Achieve Thermal Balance in Term Neonates

Hypothermia is one of the most recognized and potentially avoidable reasons for transfer of a term neonate to the NICU. Physiologic and physical factors involved in the loss of heat affect a neonate's ability to thermoregulate in extrauterine environments. At the same time, these processes are interdependently affected by hypothermia, hypoglycemia, and respiratory distress. Underlying principles and preventive measures to avoid hypothermia are presented with practical application to practice. The implementation of best practices will decrease NICU admissions that separate mothers and neonates at this critical time. Preventive measures, competent assessment guides, and early interventions offer measures to avert avoidable hypothermia-related admissions to the NICU.

Development of the Ontogenetic Self-Regulation Clock

To date, there is no overarching proposition for the ontogenetic-neurobiological basis of self-regulation. This paper suggests that the balanced self-regulatory reaction of the fetus, newborn and infant is based on a complex mechanism starting from early brainstem development and continuing to progressive control of the cortex over the brainstem. It is suggested that this balance occurs through the synchronous reactivity between the sympathetic and parasympathetic systems, both which originate from the brainstem. The paper presents an evidence-based approach in which molecular excitation-inhibition balance, interchanges between excitatory and inhibitory roles of neurotransmitters as well as cardiovascular and white matter development across gestational ages, are shown to create sympathetic-parasympathetic synchrony, including the postnatal development of electroencephalogram waves and vagal tone. These occur in developmental milestones detectable in the same time windows (sensitive periods of development) within a convergent systematic progress. This ontogenetic stepwise process is termed "the self-regulation clock" and suggest that this clock is located in the largest connection between the brainstem and the cortex, the corticospinal tract. This novel evidence-based new theory paves the way towards more accurate hypotheses and complex studies of self-regulation and its biological basis, as well as pointing to time windows for interventions in preterm infants. The paper also describes the developing indirect signaling between the suprachiasmatic nucleus and the corticospinal tract. Finally, the paper proposes novel hypotheses for molecular, structural and functional investigation of the "clock" circuitry, including its associations with other biological clocks. This complex circuitry is suggested to be responsible for the developing self-regulatory functions and their neurobehavioral correlates.

Effect of massage therapy on preterm neonate's body temperature

BACKGROUND

Low-cost care strategies can be implemented to avert the morbidity and mortality associated with hypothermia in preterm neonates.

OBJECTIVE

To determine the effect of massage therapy on body temperature of preterm neonates.

METHODS

A quasi-experimental design was conducted among 72 preterm neonates at a level II special care nursery in Western Kenya. Neonates were recruited on the third day of life and followed up for 10 days. Neonates in the intervention group were massaged three times a day for 15 minutes. Body temperature was monitored and recorded before, during and after each therapy session. Neonates in the control group received routine care: temperature monitoring three times a day, feeding and diaper change.

RESULTS

Neonates who received massage had higher mean body temperature than the control group during therapy on day 6 (p = .019) and after therapy on day 6 (p = .017) and day 8 (p = .005). A comparison within massage group (before/during, during/after, before/after) showed an increase in mean body temperature during therapy compared to before therapy (p <.001) and after therapy compared to before therapy (p <.001).

CONCLUSION

Massage therapy increases body temperature in preterm neonates.

Maternal Bonding in Early Infancy Predicts Childrens' Social Competences in Preschool Age

Background: There are many studies on mother-child-bonding with little theoretical doubt that better bonding may have a positive effect on further social development. However, there is hardly any empirical evidence. In particular, there is a lack prospective longitudinal studies. Methods: As part of a longitudinal study, bonding was assessed in a community sample of 97 healthy mothers using the Postpartum Bonding Questionnaire (PBQ) 6 weeks after birth of their child. Social competencies in the offspring were assessed using the Self- and Other-oriented Social Competencies (SOCOMP) at 5.5 years of age. A potential correlation between bonding and social competencies was tested using Spearman Rank Correlation. Results: Retention rate over 5.5 years was 77.23%. Lower Maternal Bonding Impairment Scores 6 weeks postnatally were positively related to childrens' social competences at 5.5 years of age. Conclusion: The present data confirm a positive and long-term influence of bonding on social skills and provide further evidence of the importance of parent child bonding for child development in general. This result should give reason to further investigate this relationship in depth, causally and at later points in time.

Effect of Community-Based Kangaroo Mother Care Package on Neonatal Mortality Among Preterm and Low Birthweight Infants in Rural Pakistan: Protocol for a Cluster Randomized Controlled Trial

BACKGROUND

Neonatal mortality due to preterm birth and low birthweight remains a significant challenge in Pakistan. Kangaroo mother care (KMC) is a unique, low-cost intervention proven to reduce neonatal mortality and morbidity and increase exclusive breastfeeding rates. However, KMC has not been attempted in community settings in Pakistan. We aim to implement and evaluate the effectiveness of a community-based KMC package to reduce neonatal morbidity and mortality among preterm and low birthweight (LBW) infants, which will provide evidence for policy development and the large-scale implementation of KMC across the country.

OBJECTIVE

The primary objective of this trial is to reduce neonatal mortality among preterm and LBW infants. The secondary objectives are growth (measured as weight gain), reduced incidence of possible serious bacterial infection, and increased exclusive breastfeeding and continued breastfeeding practices.

METHODS

We designed a community-based cluster randomized controlled trial in one rural district of Pakistan. Stable, LBW babies (weighing 1200 grams to 2500 grams) are included in the study. The community KMC package, consisting of the KMC kit, information and counseling material, and community mobilization through KMC champions (village volunteers), was designed after preliminary research in the same geographical location and implemented in intervention clusters. The standard essential newborn care is offered in the control clusters. Infants are recruited and followed up by independent teams of data collectors. Data are collected on the duration of skin-to-skin contact, growth, breastfeeding practices, morbidities, neonatal mortality, and neurodevelopment status. Data analysis will be conducted based on the intention to treat principle. The Cox regression model will be used to assess the primary outcome of neonatal mortality. The secondary outcomes will be evaluated using linear or logistic regression.

RESULTS

The Ethics Review Committee of Aga Khan University, Pakistan, approved the study protocol in February 2017. Data collection began in August 2019 and will be completed in December 2021. Data analyses are yet to be completed.

CONCLUSIONS

This intervention may be effective in preventing sepsis and subsequently improve survival in LBW newborns in Pakistan and other low-income and middle-income countries worldwide.

TRIAL REGISTRATION

clinicaltrials.gov NCT03545204; https://clinicaltrials.gov/ct2/show/NCT03545204.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/28156.

Increasing Early Skin-to-Skin in Extremely Low Birth Weight Infants

BACKGROUND

Early skin-to-skin care (SSC) has been shown to improve outcomes after preterm birth, including improved clinical stability and establishment of breastfeeding. Recent evidence suggests the most unstable infants get the most benefit, yet these infants are not consistently offered opportunities for SSC because of safety concerns and discomfort of the care team.

PURPOSE

To identify barriers and implement a multidimensional approach to increase SSC within the first 72 hours of life among infants born less than 28 weeks' gestation and less than 1,000 g in a Level IV university-based regional intensive care nursery.

METHODS

Using Institute of Healthcare Improvement quality improvement methodology, a multidisciplinary team identified barriers to SSC and developed targeted interventions, including a unit-specific protocol; widespread parent, staff, and provider education; and an infant readiness checklist. The primary outcome was the rate of SSC within 72 hours. The balancing measure was the rate of severe intraventricular hemorrhage (IVH). Data were collected from monthly chart review and analyzed with statistical process control charts. The aim was to increase SSC within 72 hours of birth from 7 percent to greater than 80 percent within 12 months for infants born less than 28 weeks' gestation or less than 1,000 g.

RESULTS

Between June 2017 and December 2019, there were 52 extremely preterm infants included in the project (15 preintervention and 37 postintervention). The rate of SSC within the first 72 hours increased from 7 to 84 percent. There has been no increase in any or severe IVH during the project period despite the increased rate of SSC.

IMPLICATIONS FOR PRACTICE

Implementation of multidimensional, multidisciplinary interventions for reducing barriers to early SSC in extremely preterm infants resulted in rapid adoption of SSC in the first 72 hours of life without increasing severe IVH in this high-risk population.

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.

Women's experiences of skin-to-skin cesarean birth compared to standard cesarean birth: a qualitative study

BACKGROUND

Skin-to-skin contact between mother and infant immediately after birth is recommended regardless of delivery method; however, it is less common after cesarean delivery. We aimed to describe and compare women's experiences of cesarean birth with and without skin-to-skin contact at an urban tertiary care hospital.

METHODS

In this hermeneutic phenomenologic study, we used semistructured telephone interviews from 2015 to 2018 to interview a convenience sample of women who delivered at term by scheduled skin-to-skin cesarean birth at an urban tertiary care hospital in Toronto, Ontario. Women were invited to participate if they had had a previous planned or unplanned cesarean birth and a scheduled skin-to-skin cesarean birth between 2013 and 2017. Participants were excluded if they had antenatally diagnosed conditions, they delivered before 37 weeks, they had general anesthesia, their condition was unstable at the time of surgery, a skin-to-skin cesarean birth was not possible or they declined skin-to-skin cesarean birth. Interviews were recorded, transcribed and analyzed by means of thematic analysis.

RESULTS

Ten women were interviewed 1-19 months postpartum. Four central themes emerged: support for skin-to-skin cesarean birth (women feeling supported by their families and health care providers); control (participants experiencing greater control during their skin-to-skin cesarean birth); connection with the infant, which enabled women to be active participants in their delivery, enhanced bonding and intimacy, facilitated breastfeeding and bolstered confidence during early parenthood; and logistic considerations, with participants recognizing that skin-to-skin cesarean birth required additional resources.

INTERPRETATION

These findings refine what is known about skin-to-skin cesarean birth and provide a critical perspective, that of mothers. They support the transformation of traditional operating room dynamics to a more patient-centred environment.

The Feasibility of Kangaroo Care and the Effect on Maternal Attachment for Neonates in a Pediatric Cardiac Intensive Care Unit

BACKGROUND

As survival rates in neonates with congenital heart disease have improved, research has shown they are at an increased risk for brain injury and neurodevelopmental delay. One intervention shown to have a positive impact on the development in premature and full-term newborns, as well as a positive impact on mother-infant relationship, is kangaroo care (KC). There is limited evidence to support the use of KC in infants with congenital heart disease, some of who may also be premature.

PURPOSE

The purpose of this study was to examine the safety and feasibility of introducing KC for neonates with congenital heart disease in the pediatric cardiac intensive care unit.

METHODS

A descriptive observational feasibility study was employed to evaluate the safety and efficacy of KC for this population.

RESULTS

There were 25 neonates included with 60 sessions of KC. There were no adverse events including line and tube dislodgments and physiological instability related to the use of KC.

IMPLICATIONS FOR PRACTICE

This study found KC to be safe and feasible for neonates with KC.

IMPLICATIONS FOR RESEARCH

This is the first study examining the feasibility and safety of KC in this vulnerable population of neonates. Further research should be conducted using a quasi-experimental design to investigate neurodevelopmental outcomes with a larger sample of patients.

In Touch with the Heartbeat: Newborns' Cardiac Sensitivity to Affective and Non-Affective Touch

The sense of touch is the first manner of contact with the external world, providing a foundation for the development of sensorimotor skills and socio-affective behaviors. In particular, affective touch is at the core of early interpersonal interactions and the developing bodily self, promoting the balance between internal physiological state and responsiveness to external environment. The aim of the present study is to investigate whether newborns are able to discriminate between affective touch and non-affective somatosensory stimulations and whether affective touch promotes a positive physiological state. We recorded full-term newborns' (N = 30) heart rate variability (HRV)-which reflects oscillations of heart rate associated with autonomic cardio-respiratory regulation-while newborns were presented with two minutes of affective (stroking) and non-affective (tapping) touch alternated with two minutes of resting in a within-subject design. The results revealed that non-affective touch elicits a decrease in HRV, whereas affective touch does not result in a change of HRV possibly indicating maintenance of calm physiological state. Thus, newborns showed cardiac sensitivity to different types of touch, suggesting that early somatosensory stimulation represents scaffolding for development of autonomic self-regulation with important implications on infant's ability to adaptively respond to the surrounding social and physical environment.

Between Action and Emotional Survival During the COVID-19 era: Sensorimotor Pathways as Control Systems of Transdiagnostic Anxiety-Related Intolerance to Uncertainty

Objectives: The COVID-19 pandemic and aligned social and physical distancing regulations increase the sense of uncertainty, intensifying the risk for psychopathology globally. Anxiety disorders are associated with intolerance to uncertainty. In this review we describe brain circuits and sensorimotor pathways involved in human reactions to uncertainty. We present the healthy mode of coping with uncertainty and discuss deviations from this mode. Methods: Literature search of PubMed and Google Scholar. Results: As manifestation of anxiety disorders includes peripheral reactions and negative cognitions, we suggest an integrative model of threat cognitions modulated by sensorimotor regions: "The Sensorimotor-Cognitive-Integration-Circuit." The model emphasizes autonomic nervous system coupling with the cortex, addressing peripheral anxious reactions to uncertainty, pathways connecting cortical regions and cost-reward evaluation circuits to sensorimotor regions, filtered by the amygdala and basal ganglia. Of special interest are the ascending and descending tracts for sensory-motor crosstalk in healthy and pathological conditions. We include arguments regarding uncertainty in anxiety reactions to the pandemic and derive from our model treatment suggestions which are supported by scientific evidence. Our model is based on systematic control theories and emphasizes the role of goal conflict regulation in health and pathology. We also address anxiety reactions as a spectrum ranging from healthy to pathological coping with uncertainty, and present this spectrum as a transdiagnostic entity in accordance with recent claims and models. Conclusions: The human need for controllability and predictability suggests that anxiety disorders reactive to the pandemic's uncertainties reflect pathological disorganization of top-down bottom-up signaling and neural noise resulting from non-pathological human needs for coherence in life.

Skin-to-skin contact and infant emotional and cognitive development in chronic perinatal distress

OBJECTIVE

We examined whether the timing of maternal-neonate skin-to-skin contact (SSC) predicts infant emotional and cognitive development in the context of chronic maternal perinatal stress and depressive symptoms.

STUDY DESIGN

This secondary analysis included data from a group-based prenatal care clinical trial for 37 pregnant women with low household income. Mothers completed the Perceived Stress Scale (PSS), and the Center for Epidemiologic Studies Depression Scale (CES-D) during the third trimester and postpartum. After birth, they reported timing of SSC, and completed the Infant Behavior Questionnaire-Revised Very Short Form (IBQ-R VSF) (M = 51.7 weeks, SD = 4.2). Increased PSS or CES-D score from the third trimester to post-birth indicates chronic maternal perinatal stress or depressive symptoms compared to a decrease or no change. Using hierarchical regression models, we examined if the timing of SSC makes a unique contribution in predicting infant outcomes in the context of chronic maternal perinatal stress and depressive symptoms.

RESULTS

Stress-exposed infants had less negative emotionality if SSC is provided immediately after delivery, less than 10 min after birth. The effect of SSC on effortful control in relation to chronic perinatal stress was not statistically significant. The impact of timing of SSC on negative emotionality or effortful control in relation to chronic perinatal depressive symptoms was not statistically significant.

CONCLUSION

This work implies that very early SSC may play a role in later infant emotion regulation process and could act as a protective factor in chronically stressed pregnant women.

Short-time effect of the kangaroo position on electromyographic activity of premature infants: a randomized clinical trial

OBJECTIVE

To verify the short-term influence of the kangaroo position (KP) on the electromyography activity of preterm newborns.

METHOD

A clinical study was conducted in a kangaroo unit sector (secondary and tertiary care) in the city of Recife, Brazil, with 44 preterm infants randomized to intervention (n=21) and control (n=23) groups. The KP was performed through a band that supports the newborn against the adult's thorax, in a prone and vertical position, and infants were dressed with few pieces of clothes, thus keeping skin-to-skin contact with the mother. Surface electromyography was used to investigate the muscle activity of the biceps brachii and hamstrings. The randomization of the groups was performed by the program R® (v. 3.3.1). The electromyography registrations were made at three different times: before the KP and after one and two hours of KP. In the control group, the registrations were performed at the times corresponding to those of the intervention group. The mean values of the electromyography activity among the times were analyzed by ANOVA for repeated measures and the Kruskal-Wallis test. The clinical trial was recorded in ClinicalTrials.gov (NCT02849665 - 07/28/2016).

RESULTS

In the intervention group (n=21), there was a variation of the electromyography activity values between the three recording moments for both the biceps brachii and hamstrings. In the control group (n=23), there was no statistical difference between the recording moments for both.

CONCLUSIONS

The KP increases the short-term electromyographic activity of the biceps brachii and hamstrings.

Skin-to-Skin Care Is a Safe and Effective Comfort Measure for Infants Before and After Neonatal Cardiac Surgery

OBJECTIVES

To determine the effect of skin-to-skin care on stress, pain, behavioral organization, and physiologic stability of infants with critical congenital heart disease before and after neonatal cardiac surgery.

DESIGN

A baseline response-paired design was used, with infants acting as their own controls before, during, and after skin-to-skin care at two distinct time points: once in the preoperative period (T1) and once in the postoperative period (T2).

SETTING

Cardiac ICU and step-down unit in a large metropolitan freestanding children's hospital.

SUBJECTS

Convenience sample of 30 infants admitted preoperatively for critical congenital heart disease.

INTERVENTIONS

Eligible infants were placed into skin-to-skin care for 1 hour with their biological mothers once each at T1 and T2.

MEASUREMENTS AND MAIN RESULTS

Measurements of stress (salivary cortisol), pain and behavior state (COMFORT scale), and physiologic stability (vital signs) were assessed immediately before skin-to-skin care, 30 minutes into skin-to-skin care, and 30 minutes after skin-to-skin care ended.At both T1 and T2, infant pain scores were significantly decreased (p < 0.0001) and infants moved into a calmer behavior state (p < 0.0001) during skin-to-skin care as compared to baseline. At T1, infants also had significantly reduced heart rate (p = 0.002) and respiratory rate (p < 0.0001) and increased systolic blood pressure (p = 0.033) during skin-to-skin care. At both T1 and T2, infant cortisol remained stable and unchanged from pre-skin-to-skin care to during skin-to-skin care (p = 0.096 and p = 0.356, respectively), and significantly increased from during skin-to-skin care to post-skin-to-skin care (p = 0.001 and p = 0.023, respectively). Exploratory analysis revealed differences in cortisol reactivity for infants with higher baseline cortisol (> 0.3 μg/dL) versus lower (≤ 0.3 μg/dL) prior to skin-to-skin care. Infants with higher baseline cortisol at T2 experienced significantly reduced cortisol during skin-to-skin care (p = 0.025). No significant differences in demographics or baseline variables were found between infants in either group.

CONCLUSIONS

Skin-to-skin care is a low-cost, low-risk intervention that promotes comfort and supports physiologic stability in infants before and after neonatal cardiac surgery.

Effects of acupressure, gum chewing and coffee consumption on the gastrointestinal system after caesarean section under spinal anaesthesia

This study evaluated the efficacy and safety of postoperative acupressure in the recovery of the gastrointestinal system (GIS) after caesarean section. A total of 160 primipara pregnant women delivered by caesarean section under spinal anaesthesia were randomised into four groups: group 1 (those who received acupressure), group 2 (coffee was provided three times a day), group 3 (chewed sugar-free gum for 15 min with an interval of 4 h from the second postoperative hour), and group 4 (control group). The first gas outflow and defaecation times of the women were compared among the groups. The first flatus and defaecation exit times of the women in the acupressure group were statistically earlier than those of the other groups. No difference was found among the gum-chewing, coffee, and control groups. Acupressure is effective in reducing the flatus and defaecation exit times due to GIS inactivity after abdominal surgery including caesarean section.Impact statementWhat is already known about the topic. The slowing of gastrointestinal system (GIS) motility also occurs after caesarean section aside from other surgical operations. If normal GIS movements do not occur, then several problems, such as the negative increase in the duration of breastfeeding and the mother-baby attachment during the postpartum period, may arise. Therefore, the early onset of bowel functions is important in women who give birth by caesarean section.What do the results of this study add. In the postoperative period, spontaneous GIS motility can be achieved by applying acupressure. The effective use of acupressure in the postoperative period prevents the need for pharmacological methods to eliminate the discomfort caused by the decreased motility of the GIS in women in the postpartum period.What are the implications of these findings for clinical practice and further research. Acupressure, a non-invasive, easy-to-use, and cost-effective method, plays a role in preventing GIS immotility. Midwives or obstetricians should receive training on acupuncture or acupressure and should ensure that acupuncture or acupressure practices are converted into a protocol to be implemented in the postoperative period. With this transformation, the treatment methods to increase GIS motility and the reduced medication use can decrease the mother's and the newborn's duration of hospital stay and the cost of hospitalisation.

Longer duration of kangaroo care improves neurobehavioral performance and feeding in preterm infants: a randomized controlled trial

AIM

To investigate the effect of kangaroo care (KC) and its duration on neurobehavioral performance, stress response, breastfeeding success, and vital signs in premature infants.

METHODS

One hundred and twenty premature infants were randomized to receive either KC for 60 min daily, KC for 120 min daily or conventional care (controls) for at least 7 days. Salivary cortisol was measured before and after the first KC session and then after 7 days. Temperature, respiration rate, heart rate, and oxygen saturation were recorded, before and after KC. Neonates were evaluated by the Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS).

RESULTS

Both KC groups demonstrated higher scores for attention, arousal, regulation, nonoptimal reflexes, and quality of movements and lower scores for handling, excitability, and lethargy, compared to controls (p < 0.05). Both KC groups had higher infant breastfeeding assessment tool score and reached full enteral feeds faster than controls (p < 0.05). After the first KC session, improvement in O₂ saturation and temperature was observed in KC 120-min group compared with the KC 60-min group (p < 0.05). Salivary cortisol decreased in both KC groups compared with controls after 7 days (p < 0.05).

CONCLUSION

Preterm neonates who receive KC for long durations reach full enteral feeds faster, have better breastfeeding success, neurobehavioral performance, thermal control, and tissue oxygenation.

Nonpharmacologic Management of Pain During Common Needle Puncture Procedures in Infants: Current Research Evidence and Practical Considerations: An Update

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 that may be used for these painful procedures, including swaddling/containment, pacifier/non-nutritive sucking, rocking/holding, breastfeeding and breastmilk, skin-to-skin care, sweet tasting solutions, music therapy, sensorial saturation, and parental presence. Adoption these interventions into routine clinical practice is feasible and should be a standard of care in quality health care for infants. This review summarizes the epidemiology of pain from common needle puncture procedures in infants, the effectiveness of nonpharmacologic interventions, implementation considerations, and unanswered questions.

WITHDRAWN: Short-time effect of the kangaroo position on electromyographic activity of premature infants: a randomized clinical trial

The Publisher regrets that this article is an accidental duplication of an article that has already been published, https://doi.org/. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

The evolution of the science of kangaroo (mother) care (skin-to-skin contact)

In the early 1970s, researchers in Ohio, USA, investigated the effects of "Extra Contact" between mothers and their infants early after birth. The "Extra Contact" consisted of the skin-to-skin holding of the newborn infant on the mother's bare chest as soon as possible after birth. In the mid 1970s, Rey and Martinez in Bogota Colombia started investigating the same care method and they called it "Kangaroo Care" (KC). Infants are held upright, skin-to-skin on the mother's bare chest. KC, also referred to as Kangaroo Mother Care or Skin-to-Skin Contact, has been and continue to be investigated for its effects on a plethora of infant, maternal and family outcomes. Evolution of our understanding of the advantages of KC has dramatically changed the care of infants including at risk infants. This article provides a look at the past and present. It also provides insight on how we can shape the future to provide the optimal care for infants, mothers, and the whole family.

Randomized controlled trial investigating the effects of a breastfeeding relaxation intervention on maternal psychological state, breast milk outcomes, and infant behavior and growth

BACKGROUND

Biological signaling and communication between mothers and infants during breastfeeding may shape infant behavior and feeding. This signaling is complex and little explored in humans, although it is potentially relevant for initiatives to improve breastfeeding rates.

OBJECTIVES

The aim of this study was to investigate physiological and psychological aspects of mother-infant signaling during breastfeeding experimentally, testing the effects of a relaxation intervention on maternal psychological state, breast milk intake, milk cortisol levels, and infant behavior and growth.

METHODS

Primiparous breastfeeding mothers and full-term infants were randomly assigned to receive relaxation therapy [intervention relaxation group; n = 33 (RG)] or to the control group [n = 31 (CG); no relaxation therapy] at 2 wk postpartum. Both groups received standard breastfeeding support. Home visits were conducted at 2 (HV1), 6 (HV2), 12 (HV3) and 14 (HV4) wk to measure maternal stress and anxiety, breast milk intake and milk cortisol, and infant behavior and growth.

RESULTS

RG mothers had lower stress scores postintervention than the CG (HV3 ∆ = -3.13; 95% CI: -5.9, -0.3) and lower hindmilk cortisol at HV1 (∆ = -44.5%; 95% CI: -76.1%, -12.9%) but not at HV2. RG infants had longer sleep duration (∆ = 82 min/d; 95% CI: 16, 149 min/d) at HV2 and higher gains in weight and body mass index standardized deviation score than the CG infants (∆ = 0.76; 95% CI: 0.3, 1.22; and ∆ = 0.59; 95% CI: 0.09, 1.1, respectively). RG infants had a mean milk intake at HV3 that was 227 g/d higher than that of the CG infants (P = 0.031) after controlling for gender and milk intake at HV1.

CONCLUSIONS

The trial shows the effectiveness of a simple relaxation intervention for improving maternal and infant outcomes and identifies some potential signaling mechanisms for investigation in future and larger studies, especially in settings where mothers are more stressed, such as those with preterm or low birth weight infants. This trial was registered at clinicaltrials.gov as NCT01971216.

The human newborn's umwelt: Unexplored pathways and perspectives

Historically, newborns, and especially premature newborns, were thought to "feel nothing." However, over the past decades, a growing body of evidence has shown that newborns are aware of their environment, but the extent and the onset of some sensory capacities remain largely unknown. The goal of this review is to update our current knowledge concerning newborns' perceptual world and how ready they are to cope with an entirely different sensory environment following birth. We aim to establish not only how and when each sensory ability arises during the pre-/postbirth period but also discuss how senses are studied. We conclude that although many studies converge to show that newborns are clearly sentient beings, much is still unknown. Further, we identify a series of internal and external factors that could explain discrepancies between studies, and we propose perspectives for future studies. Finally, through examples from animal studies, we illustrate the importance of this detailed knowledge to pursue the enhancement of newborns' daily living conditions. Indeed, this is a prerequisite for assessing the effects of the physical environment and routine procedures on newborns' welfare.

Supporting Optimal Neurodevelopmental Outcomes in Infants and Children With Congenital Heart Disease

Improved survival has led to increased recognition of developmental delays in infants and children with congenital heart disease. Risk factors for developmental delays in congenital heart disease survivors may not be modifiable; therefore, it is important that lifesaving, high-technology critical care interventions be combined with nursing interventions that are also developmentally supportive. Implementing developmental care in a pediatric cardiac intensive care unit requires change implementation strategies and widespread support from all levels of health care professionals. This manuscript reviews developmentally supportive interventions such as massage, developmentally supportive positioning, kangaroo care, cue-based feeding, effective pain/anxiety management, and procedural preparation and identifies strategies to implement developmentally supportive interventions in the care of infants and children with congenital heart disease. Improving developmental support for these infants and children at high risk for developmental delay may improve their outcomes and help promote family-centered care.

Sucrose vs. skin to skin care for preterm neonatal pain control-a randomized control trial

OBJECTIVE

To compare the efficacy of SSC with oral Sucrose for pain management in preterm neonates.

METHODOLOGY

Parallel-group, assessor-blinded randomized control trial conducted from February-June 2017 at a level 3B-NICU. Hundred preterm neonates (29-0/7 to 36-6/7 weeks gestational age) requiring heel-stick were randomly assigned (1:1), to SSC (50, Group-A) and Sucrose (50, Group-B). In Group-A, SSC was provided at least 10 min before the procedure. In Group-B, 0.2 ml of oral Sucrose was provided 2 min before the procedure. Blinded assessment of Premature Infant Pain Profile (PIPP) score was done 30 s post-procedure using recorded videos.

RESULTS

Baseline variables were [Mean(SD)] gestational age [32.79(2.34) weeks], age [14.04(11.10) days] and birth weight [1.62(0.35) kilograms]. PIPP score was less in group- A vs. B but could not achieve statistical significance [Mean(SD): 7.74(2.43) vs. 8.1(2.82), p = 0.50 CI of the difference: (-1.40,0.68)].

CONCLUSIONS

SSC and Sucrose have comparable efficacy in managing pain in premature neonates.

Association between breastfeeding and better preserved cognitive ability in an elderly cohort of Finnish men

BACKGROUND

Being breastfed in infancy has been shown to benefit neurodevelopment. However, whether the benefits persist to old age remains unclear.

METHODS

We examined the associations between breastfeeding and its duration on cognitive ability in young adulthood and old age, and on aging-related cognitive change over five decades. In total, 931 men from the Helsinki Birth Cohort Study born in 1934-1944 in Finland took the Finnish Defence Forces Basic Intellectual Ability Test (total and verbal, arithmetic and visuospatial subtest scores) twice, at ages 20.2 and 67.9 years, and had data on breastfeeding (yes v. no) and its duration ('never breastfed', 'up to 3', '3 to 6' and '6 or more months'). Linear and mixed model regressions tested the associations.

RESULTS

At 20.2 years, breastfed men had higher cognitive ability total and visuospatial subtest scores [mean differences (MDs) ranged between 3.0-3.9, p values < 0.013], and its longer duration predicted higher cognitive ability total and arithmetic and visuospatial subtest scores (MDs ranged between 3.0 and 4.8, p values < 0.039). At 67.9 years, breastfed men had higher total cognitive ability and all subtest scores (MDs ranged between 2.6 and 3.4, p values < 0.044) and its longer duration predicted all cognitive ability scores (MDs ranged between 3.1 and 4.7, p values < 0.050). Verbal subtest scores decreased over five decades in men who were never breastfed or were breastfed for 3 months or less, and increased in those breastfed for longer than 3 months.

CONCLUSIONS

Neurodevelopmental advantages of breastfeeding and its longer duration persist into old age, and longer duration of breastfeeding may benefit aging-related change, particularly in verbal reasoning ability.

Interventions to prevent hypothermia at birth in preterm and/or low birth weight infants

BACKGROUND

Newborn admission temperature is a strong predictor of outcomes across all gestations. Hypothermia immediately after birth remains a worldwide issue and, if prolonged, is associated with harm. Keeping preterm infants warm is difficult even when recommended routine thermal care guidelines are followed in the delivery room.

OBJECTIVES

To assess the efficacy and safety of interventions designed for prevention of hypothermia in preterm and/or low birth weight infants applied within 10 minutes after birth in the delivery room, compared with routine thermal care or any other single/combination of intervention(s) also designed for prevention of hypothermia in preterm and/or low birth weight infants applied within 10 minutes after birth in the delivery room.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 5), MEDLINE via PubMed (1966 to 30 June 2016), Embase (1980 to 30 June 2016), and CINAHL (1982 to 30 June 2016). We also searched clinical trials databases, conference proceedings, and reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Trials using randomised or quasi-randomised allocations to test interventions designed to prevent hypothermia (apart from 'routine' thermal care) applied within 10 minutes after birth in the delivery room for infants at < 37 weeks' gestation and/or birth weight ≤ 2500 grams.

DATA COLLECTION AND ANALYSIS

We used Cochrane Neonatal methods when performing data collection and analysis.

MAIN RESULTS

Twenty-five studies across 15 comparison groups met the inclusion criteria, categorised as: barriers to heat loss (18 studies); external heat sources (three studies); and combinations of interventions (four studies).Barriers to heat loss Plastic wrap or bag versus routine carePlastic wraps improved core body temperature on admission to the neonatal intensive care unit (NICU) or up to two hours after birth (mean difference (MD) 0.58°C, 95% confidence interval (CI) 0.50 to 0.66; 13 studies; 1633 infants), and fewer infants had hypothermia on admission to the NICU or up to two hours after birth (typical risk ratio (RR) 0.67, 95% CI 0.62 to 0.72; typical risk reduction (RD) -0.25, 95% CI -0.29 to -0.20; number needed to treat for an additional beneficial outcome (NNTB) 4, 95% CI 4 to 5; 10 studies; 1417 infants). Risk of hyperthermia on admission to the NICU or up to two hours after birth was increased in infants in the wrapped group (typical RR 3.91, 95% CI 2.05 to 7.44; typical RD 0.04, 95% CI 0.02 to 0.06; number needed to treat for an additional harmful outcome (NNTH) 25, 95% CI 17 to 50; 12 studies; 1523 infants), but overall, fewer infants receiving plastic wrap were outside the normothermic range (typical RR 0.75, 95% CI 0.69 to 0.81; typical RD -0.20, 95% CI -0.26 to -0.15; NNTH 5, 95% CI 4 to 7; five studies; 1048 infants).Evidence was insufficient to suggest that plastic wraps or bags significantly reduce risk of death during hospital stay or other major morbidities, with the exception of reducing risk of pulmonary haemorrhage.Evidence of practices regarding permutations on this general approach is still emerging and has been based on the findings of only one or two small studies.External heat sourcesEvidence is emerging on the efficacy of external heat sources, including skin-to-skin care (SSC) versus routine care (one study; 31 infants) and thermal mattress versus routine care (two studies; 126 infants).SSC was shown to be effective in reducing risk of hypothermia when compared with conventional incubator care for infants with birth weight ≥ 1200 and ≤ 2199 grams (RR 0.09, 95% CI 0.01 to 0.64; RD -0.56, 95% CI -0.84 to -0.27; NNTB 2, 95% CI 1 to 4). Thermal (transwarmer) mattress significantly kept infants ≤ 1500 grams warmer (MD 0.65°C, 95% CI 0.36 to 0.94) and reduced the incidence of hypothermia on admission to the NICU, with no significant difference in hyperthermia risk.Combinations of interventionsTwo studies (77 infants) compared thermal mattresses versus plastic wraps or bags for infants at ≤ 28 weeks' gestation. Investigators reported no significant differences in core body temperature nor in the incidence of hypothermia, hyperthermia, or core body temperature outside the normothermic range on admission to the NICU.Two additional studies (119 infants) compared plastic bags and thermal mattresses versus plastic bags alone for infants at < 31 weeks' gestation. Meta-analysis of these two studies showed improvement in core body temperature on admission to the NICU or up to two hours after birth, but an increase in hyperthermia. Data show no significant difference in the risk of having a core body temperature outside the normothermic range on admission to the NICU nor in the risk of other reported morbidities.

AUTHORS' CONCLUSIONS

Evidence of moderate quality shows that use of plastic wraps or bags compared with routine care led to higher temperatures on admission to NICUs with less hypothermia, particularly for extremely preterm infants. Thermal mattresses and SSC also reduced hypothermia risk when compared with routine care, but findings are based on two or fewer small studies. Caution must be taken to avoid iatrogenic hyperthermia, particularly when multiple interventions are used simultaneously. Limited evidence suggests benefit and no evidence of harm for most short-term morbidity outcomes known to be associated with hypothermia, including major brain injury, bronchopulmonary dysplasia, retinopathy of prematurity, necrotising enterocolitis, and nosocomial infection. Many observational studies have shown increased mortality among preterm hypothermic infants compared with those who maintain normothermia, yet evidence is insufficient to suggest that these interventions reduce risk of in-hospital mortality across all comparison groups. Hypothermia may be a marker for illness and poorer outcomes by association rather than by causality. Limitations of this review include small numbers of identified studies; small sample sizes; and variations in methods and definitions used for hypothermia, hyperthermia, normothermia, routine care, and morbidity, along with lack of power to detect effects on morbidity and mortality across most comparison groups. Future studies should: be adequately powered to detect rarer outcomes; apply standardised morbidity definitions; focus on longer-term outcomes, particularly neurodevelopmental outcomes.

The Positive Association Between Duration of Skin-to-Skin Contact and Blood Glucose Level in Full-Term Infants

The aim of this study was to evaluate the contribution of the duration of skin-to-skin contact (SSC) on blood glucose levels at 2 hours after birth in healthy full-term infants. This observational study was done at one of the baby-friendly hospitals located in Aichi, Japan in 2009. Sixty newborn infants who were born vaginally from uncomplicated pregnancies were participated. All infants were held SSC within 5 minutes. All data regarding neonatal information, blood glucose levels at 2 hours of age, and maternal information were obtained from their medical history. Multiple linear regression analysis was performed to identify the independent contribution of the duration of SSC. The mean duration of SSC was 59.6 ± 13.6 minutes (range: 11.0-97.0 minutes) and the infant blood glucose level was 53.1 ± 9.5 (range: 30.0-80.0 mg/dL) mg/dL. The duration of SSC (β [95% confidence interval] = .282 [range: 0.037-0.357], standardized β = .282, P < .017) was significantly and positively associated with infant blood glucose levels independent of gestational age, birth weight, sex, length of second-stage labor, and mode of delivery. Thus, the longer early SSC was associated with higher blood glucose level at 2 hours of age in healthy full-term infants.

Care Through the Newborn's Eyes

Separation of mothers and infants after birth is standard practice for many hospitals, yet not evidence-based. Nonseparation clearly has numerous benefits. However, newborns lack a voice to make choices to direct their course of care. The evidence supports nonseparation strategies for mothers and infants that promote attachment, physiologic regulation, nutrition, sleep, communication, and management of stress/pain. Moreover, the evidence is compelling that nonseparation is essential. The time has come to act on the evidence and begin seeing the care we provide through the newborn's eyes.

Systematic Review of Skin-to-Skin Care for Full-Term, Healthy Newborns

OBJECTIVE

To determine the effect of skin-to-skin mother-infant holding, touch, and/or massage on full-term, healthy newborns and their primary caregivers.

DATA SOURCES

A seven-member scientific advisory panel searched the databases PubMed, CINAHL, and Scopus using the search terms massage, skin-to-skin contact, kangaroo care, touch, therapeutic touch, and full-term newborns for research with human participants published in English with no date parameters.

STUDY SELECTION

The initial search yielded 416 articles. After reviewing titles and retaining only articles that met the review criteria, 280 articles remained. The panel co-chairs reviewed and discussed the abstracts of these articles and retained 90 for review.

DATA EXTRACTION

Each article was assigned to one panel member and one co-chair for review. Members of the panel met via teleconference to present articles and to determine whether they had scientific merit and addressed the research question. Articles that did not meet these standards were eliminated. Forty articles included relevant evidence: 33 articles on skin-to-skin holding and 7 on infant massage.

DATA SYNTHESIS

We created a table that included the purpose, design, and findings of each study. This information was synthesized into a feasibility report by the co-chairs.

CONCLUSION

Evidence supports recommendations for skin-to-skin care for all full-term, healthy newborns. Although there is inadequate evidence to recommend massage as standard care for all newborns, massage has been shown to help consolidate sleep patterns and reduce jaundice.

Increase in Oxytocin From Skin-to-Skin Contact Enhances Development of Parent–Infant Relationship

Objective:

To examine changes that occur in infant and parent salivary oxytocin (OT) and salivary cortisol (SC) levels during skin-to-skin contact (SSC) and whether SSC alleviates parental stress and anxiety while also supporting mother–father–infant relationships.

Methods:

This randomized crossover study was conducted in the neonatal intensive care unit (NICU) with a sample of 28 stable preterm infants and their parents. Saliva samples were collected from infants, mothers, and fathers on Days 1 and 2 (1/parent) for OT and cortisol measurement pre-SSC, during a 60-min SSC session, and a 45-min post-SSC. Parental anxiety was measured at the same time points. Parent–infant interaction was examined prior to discharge on Day 3 via video for synchrony and responsiveness using Dyadic Mutuality Coding.

Results:

Salivary OT levels increased significantly during SSC for mothers ( p < .001), fathers ( p < .002), and infants ( p < .002). Infant SC levels decreased significantly ( p < .001) during SSC as compared to before and after SSC. Parent anxiety scores were significantly related to parent OT and SC levels. Parents with higher OT levels exhibited more synchrony and responsiveness ( p < .001) in their infant interactions.

Conclusion:

This study addresses a gap in understanding the mechanisms linking parent–infant contact to biobehavioral responses. SSC activated OT release and decreased infant SC levels. Facilitation of SSC may be an effective intervention to reduce parent and infant stress in the NICU. Findings advance the exploration of OT as a potential moderator for improving responsiveness and synchrony in parent–infant interactions.

Effects of infant massage on state anxiety in mothers of preterm infants prior to hospital discharge

AIMS AND OBJECTIVES

This study evaluated the effect of infant massage on anxiety in mothers of preterm infants who discharged from the neonatal intensive care unit.

BACKGROUND

Birth of preterm infants commonly leads to great levels of distress and anxiety in mothers. Although various methods have been suggested to help mothers cope with such stressful conditions, the effects of infant massage have not been adequately studied in mothers.

DESIGN

This was a quasi-experimental clinical trial.

METHODS

Overall, in 70 mothers and their preterm infants who scheduled to be discharged within 24 hours, State-Trait Anxiety Inventory scale (Spielberger) was completed for mothers in both groups in the morning of the day before discharge. The experimental group received eight minutes of massage including two standard similar parts (each part four minutes). The massage was repeated in two parts on the day of discharge, and then, state anxiety was re-measured using Spielberg's scale for all mothers. The control group received no intervention.

RESULTS

The results showed that on the day of discharge, there was a significant difference in the overall mean score of maternal state anxiety between the two groups (p < 0·002), although not in the severity of maternal state anxiety. In both groups, the mean score of maternal state anxiety was significantly decreased on the day of discharge (p < 0·001).

CONCLUSIONS

The findings provide evidence that infant massage by mother has an effect on the state anxiety of mothers of preterm infants, so it is recommended that mothers apply massage for preterm infants to improve their mental health.

RELEVANCE TO CLINICAL PRACTICE

Mothers of preterm infants can promote mental health by continuing massage of their infants at home.

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.

Continuing Education Module-Kangaroo Mother Care 2: Potential Beneficial Impacts on Brain Development in Premature Infants

Kangaroo mother care (KMC) involves infant skin-to-skin contact with the mother from as soon as possible after birth, exclusive breastfeeding, early discharge from the health facility, and supportive follow-up at home. Much evidence supports use of KMC clinically as an aid to mitigating some detrimental features of prematurity. This article-the second of two-explores impairments in brain development because of uncongenial inputs from the postnatal therapeutic environment of premature infants, not encountered in utero, and some of their negative neurobehavioral, psychosocial, sociocultural, and economic implications. It is concluded that evidence favoring the use of KMC in stable preterm infants is very strong and that, as noted by others, barriers to implementation of KMC, apart from infant infirmity, are mainly because of hesitancy from parents, health-care professional, and/or institutions, which may be unfounded.

Early skin-to-skin contact for mothers and their healthy newborn infants

BACKGROUND

Mother-infant separation post birth is common. In standard hospital care, newborn infants are held wrapped or dressed in their mother's arms, placed in open cribs or under radiant warmers. Skin-to-skin contact (SSC) begins ideally at birth and should last continually until the end of the first breastfeeding. SSC involves placing the dried, naked baby prone on the mother's bare chest, often covered with a warm blanket. According to mammalian neuroscience, the intimate contact inherent in this place (habitat) evokes neuro-behaviors ensuring fulfillment of basic biological needs. This time frame immediately post birth may represent a 'sensitive period' for programming future physiology and behavior.

OBJECTIVES

To assess the effects of immediate or early SSC for healthy newborn infants compared to standard contact on establishment and maintenance of breastfeeding and infant physiology.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (17 December 2015), made personal contact with trialists, consulted the bibliography on kangaroo mother care (KMC) maintained by Dr Susan Ludington, and reviewed reference lists of retrieved studies.

SELECTION CRITERIA

Randomized controlled trials that compared immediate or early SSC with usual hospital care.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

We included 46 trials with 3850 women and their infants; 38 trials with 3472 women and infants contributed data to our analyses. Trials took place in 21 countries, and most recruited small samples (just 12 trials randomized more than 100 women). Eight trials included women who had SSC after cesarean birth. All infants recruited to trials were healthy, and the majority were full term. Six trials studied late preterm infants (greater than 35 weeks' gestation). No included trial met all criteria for good quality with respect to methodology and reporting; no trial was successfully blinded, and all analyses were imprecise due to small sample size. Many analyses had statistical heterogeneity due to considerable differences between SSC and standard care control groups. Results for womenSSC women were more likely than women with standard contact to be breastfeeding at one to four months post birth, though there was some uncertainty in this estimate due to risks of bias in included trials (average risk ratio (RR) 1.24, 95% confidence interval (CI) 1.07 to 1.43; participants = 887; studies = 14; I² = 41%; GRADE: moderate quality). SSC women also breast fed their infants longer, though data were limited (mean difference (MD) 64 days, 95% CI 37.96 to 89.50; participants = 264; studies = six; GRADE:low quality); this result was from a sensitivity analysis excluding one trial contributing all of the heterogeneity in the primary analysis. SSC women were probably more likely to exclusively breast feed from hospital discharge to one month post birth and from six weeks to six months post birth, though both analyses had substantial heterogeneity (from discharge average RR 1.30, 95% CI 1.12 to 1.49; participants = 711; studies = six; I² = 44%; GRADE: moderate quality; from six weeks average RR 1.50, 95% CI 1.18 to 1.90; participants = 640; studies = seven; I² = 62%; GRADE: moderate quality).Women in the SCC group had higher mean scores for breastfeeding effectiveness, with moderate heterogeneity (IBFAT (Infant Breastfeeding Assessment Tool) score MD 2.28, 95% CI 1.41 to 3.15; participants = 384; studies = four; I² = 41%). SSC infants were more likely to breast feed successfully during their first feed, with high heterogeneity (average RR 1.32, 95% CI 1.04 to 1.67; participants = 575; studies = five; I² = 85%). Results for infantsSSC infants had higher SCRIP (stability of the cardio-respiratory system) scores overall, suggesting better stabilization on three physiological parameters. However, there were few infants, and the clinical significance of the test was unclear because trialists reported averages of multiple time points (standardized mean difference (SMD) 1.24, 95% CI 0.76 to 1.72; participants = 81; studies = two; GRADE low quality). SSC infants had higher blood glucose levels (MD 10.49, 95% CI 8.39 to 12.59; participants = 144; studies = three; GRADE: low quality), but similar temperature to infants in standard care (MD 0.30 degree Celcius (°C) 95% CI 0.13 °C to 0.47 °C; participants = 558; studies = six; I² = 88%; GRADE: low quality). Women and infants after cesarean birthWomen practicing SSC after cesarean birth were probably more likely to breast feed one to four months post birth and to breast feed successfully (IBFAT score), but analyses were based on just two trials and few women. Evidence was insufficient to determine whether SSC could improve breastfeeding at other times after cesarean. Single trials contributed to infant respiratory rate, maternal pain and maternal state anxiety with no power to detect group differences. SubgroupsWe found no differences for any outcome when we compared times of initiation (immediate less than 10 minutes post birth versus early 10 minutes or more post birth) or lengths of contact time (60 minutes or less contact versus more than 60 minutes contact).

AUTHORS' CONCLUSIONS

Evidence supports the use of SSC to promote breastfeeding. Studies with larger sample sizes are necessary to confirm physiological benefit for infants during transition to extra-uterine life and to establish possible dose-response effects and optimal initiation time. Methodological quality of trials remains problematic, and small trials reporting different outcomes with different scales and limited data limit our confidence in the benefits of SSC for infants. Our review included only healthy infants, which limits the range of physiological parameters observed and makes their interpretation difficult.

Maternal touch and infant affect in the Still Face Paradigm: A cross-cultural examination

Touch between mother and infant plays an important role in development starting from birth. Cross-cultural differences surrounding rearing practices have an influence on parent-infant interaction, including types of touch used and the development of emotional regulation. This study was designed to investigate maternal touch and infant emotional regulation in infant-mother dyads from Ecuador (n=25) and Hispanic dyads from the United States (US) (n=26). Mothers and their 4-month-old full-term infants participated in the Still Face Paradigm. Second-by-second coding of maternal touch and infant affect was completed. Overall the analyses showed that Ecuadorian mothers used more nurturing and accompaniment touch and less attention seeking touch than US Hispanic mothers during the pre-stressor (baseline) episode. Lagged multilevel models were used to investigate the effect of the different types of touch on infant emotional regulation in the groups for the episodes. The data suggest that playful touch had a significant increase in infant affect, whereas accompaniment and attention-seeking touch had a significant decrease in infant affect. Overall, this study provides support for the role of touch in mother-infant synchronicity in relation to infant's emotional regulation. Identifying touch that is more calming is important to foster emotional regulation in infancy, which can have important implications for development.