Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns

Skin Barrier Function in Neonates and Infants

This review focuses on the skin barrier function in neonates and infants, emphasizing the structural and functional differences compared to adult skin. Neonatal and infant skin is thinner, more permeable, and less developed, which makes it more vulnerable to irritants, infections, and dehydration. Additionally, the critical role of skin pH in maintaining barrier function is discussed, noting significant changes in pH levels during early life. This review also examines the relationship between the onset of atopic dermatitis and skin barrier function, underscoring the importance of maintaining skin barrier integrity from birth to reduce the risk of atopic diseases. Finally, recommendations are offered for skincare practices in neonates and infants, emphasizing the use of mild, fragrance-free products and the importance of tailoring skincare regimens to meet the specific needs of each neonate or infant.

The use of in-hospital guidelines for prevention of sudden unexpected postnatal collapse: A national survey

AIM

Sudden unexpected postnatal collapse is a life-threatening event and may occur in any newborn infant. Safe skin-to-skin contact, and awareness of sudden unexpected postnatal collapse are key to its prevention. The aim of this study was to survey the presence of skin-to-skin contact and/or sudden unexpected postnatal collapse protocols in the 70 perinatal centres in the Netherlands.

METHODS

We performed a survey among Dutch paediatricians to examine the safe skin-to-skin contact and sudden unexpected postnatal collapse protocols.

RESULTS

We received data from 59/70 (85%) perinatal centres. At least one case of sudden unexpected postnatal collapse was reported in 35/59 (59%) of these centres. Nearly half the centres had safe skin-to-skin contact and/or sudden unexpected postnatal collapse protocols. Ultimately, 16 protocols were available for analysis. They showed considerable differences in the type of perinatal care provided. Most protocols lacked recently published insights on safe skin-to-skin contact. Besides, protocols failed to incorporate awareness of and knowledge on how to prevent sudden unexpected postnatal collapse.

CONCLUSION

This study underlines the importance of drawing up uniform, multidisciplinary guidelines containing recommendations for the prevention of sudden unexpected postnatal collapse in the Netherlands.

Changes in maternity care policies and practices that support breastfeeding as measured by the Ten Steps to Successful Breastfeeding - United States, 2018-2022

BACKGROUND

Experiences during the birth hospitalization affect a family's ability to establish and maintain breastfeeding. The Ten Steps to Successful Breastfeeding (Ten Steps) describe evidence-based hospital policies and practices shown to improve breastfeeding outcomes. We aim to describe hospitals' implementation of the Ten Steps, changes over time, and hospitals' implementation of a majority (≥ 6) of the Ten Steps by hospital characteristics and state.

METHODS

The biennial Maternity Practices in Infant Nutrition and Care (mPINC) survey assesses all hospitals in the United States (including the District of Columbia and territories) that routinely provide maternity care services. We analyzed data from 2018, 2020, and 2022 survey cycles to describe trends in the prevalence of hospitals implementing maternity care policies and practices that are consistent with the Ten Steps. Differences were calculated using the absolute difference in percentage-points between 2018 and 2022.

RESULTS

Between 2018 and 2022, the percentage of hospitals that implemented Step 2: Staff Competency and Step 5: Support Mothers with Breastfeeding increased 12 and 8 percentage points, respectively. The percentage of hospitals that implemented Step 6: Exclusive Breastfeeding Among Breastfed Infants was 7 percentage points lower in 2022 than 2018. Implementation of the remaining seven steps did not change by more than 5 percentage points in either direction between 2018 and 2022. Nationally, the percentage of hospitals that implemented ≥ 6 of the Ten Steps increased from 44.0% in 2018 to 51.1% in 2022. Differences were seen when comparing implementation of ≥ 6 of the Ten Steps by hospital characteristics including state, hospital size, and highest level of neonatal care offered.

CONCLUSIONS

Nationally, maternity care policies and practices supportive of breastfeeding continued to improve; however, certain practices lost progress. Differences in implementation of the Ten Steps were observed across states and by certain hospital characteristics, suggesting more work is needed to ensure all people receive optimal breastfeeding support during their delivery hospitalization.

Skin-to-skin care (SSC) for term and preterm infants

Skin-to-skin care (SSC) is an important part of parent and infant care during the neonatal period and into infancy. SSC should be initiated immediately after birth and practiced as a standard of care in all settings, as well as in the home. There is strong evidence that SSC has a positive effect on breastfeeding and human milk feeding in both term and preterm infants, as well as on mortality, cardiopulmonary stability, and thermoregulation. SSC reduces pain and infant stress, enhances parent-infant bonding, has neurodevelopmental benefits, and has positive effects on parental mental health. The safety and feasibility of providing SSC has been established in term and preterm infants, and SSC is recommended as best practice for all infants. The benefits of SSC outweigh the risks in most situations, and despite challenges, care providers should implement procedures and accommodations to ensure that SSC occurs as a safe and positive experience for the parent, family, infant, and health care team. This statement includes all families as defined and determined by themselves, and recognizes that health communication, language, and terminology must be individualized to meet specific family needs by the health care team.

Les soins peau-à-peau chez les nourrissons à terme et prématurés

Les soins peau-à-peau (SPP) sont un aspect important des soins au parent et au nourrisson pendant la période néonatale et la première enfance. Ils doivent être entrepris immédiatement après la naissance et faire partie des soins standards dans tous les milieux, y compris à la maison. Selon de solides données probantes, les SPP ont un effet positif sur l'allaitement et l'alimentation par du lait humain, tant chez les nourrissons à terme que prématurés, de même que sur la mortalité, la stabilité cardiorespiratoire et la thermorégulation. Les SPP réduisent la douleur et le stress chez les nourrissons, accroissent l'attachement entre le parent et son nourrisson et ont des effets bénéfiques sur le neurodéveloppement de l'enfant ainsi que sur la santé mentale des parents. Le caractère sécuritaire et la faisabilité des SPP sont établis chez les nourrissons à terme et prématurés, et ces soins sont recommandés dans le cadre d'une pratique exemplaire auprès de tous les nourrissons. Les avantages des SPP sont supérieurs aux risques dans la plupart des situations, et malgré les défis qui y sont associés, les dispensateurs de soins devraient adopter des protocoles et prévoir des adaptations pour s'assurer que les SPP soient une expérience positive et sécuritaire pour le parent, la famille, le nourrisson et l'équipe soignante. Le présent document de principes s'adresse à toutes les familles, telles qu'elles se définissent et se déterminent elles-mêmes, et tiennent compte de l'importance de personnaliser la communication, le langage et la terminologie en matière de santé pour que l'équipe soignante réponde aux besoins particuliers de la famille.

Implementing the practice of early skin-to-skin contact among infants ≥35 weeks gestation born vaginally: a quality improvement study

BACKGROUND

Early skin-to-skin contact (SSC) at birth has been shown to improve neonatal outcomes due to enhanced cardiorespiratory stability, thermoregulation and breastfeeding success.

LOCAL PROBLEM

The practice of early SSC was virtually non-existent in our delivery room (DR).

METHODS AND INTERVENTIONS

The study was conducted in a newly established tertiary care teaching hospital in Western Rajasthan, India. We aimed to improve the median duration of early SSC from 0 min to at least 60 min over 24 weeks in our DR. A quality improvement (QI) team was formed, and all inborn infants ≥35 weeks born vaginally from 9 March 2017 were included. Using the tools of point-of-care QI, we found the lack of standard operating procedure, lack of knowledge among nursing staff regarding early SSC, routine shifting of all infants to radiant warmer, the practice of prioritising birthweight documentation and vitamin K administration as the major hindrances to early SSC. Various change ideas were implemented and tested sequentially through multiple plan-do-study-act (PDSA) cycles to improve the duration of early SSC. Interventions included framing a written policy for SSC, sensitising the nursing staff and resident doctors, actively delaying the alternate priorities, making early SSC a shared responsibility among paediatricians, obstetricians, nursing staff and family members, and continuing SSC in the recovery area of the DR complex.

RESULTS

The duration of early SSC increased from 0 to 67 min without any additional resources. The practice of SSC got well established in the system as reflected by a sustained improvement of 63 min and 72 min, respectively, at the end of 2 months and 4 years after study completion.

CONCLUSION

Using the QI approach, we established and sustained the practice of early SSC for more than 60 min in our unit by using system analysis and testing change ideas in sequential PDSA cycles.

Sudden Unexpected Postnatal Collapse: Review and Management

Sudden unexpected postnatal collapse (SUPC) of healthy newborns is a catastrophic event caused by cardiorespiratory collapse in a healthy newborn. The most common cause of SUPC is poor positioning of the newborn during skin-to-skin contact or breastfeeding when the newborn is not being observed by a health professional, attentive parent, or caretaker. Maternal/newborn health care professionals need to know about the essential information, definitions, incidence, risk factors, clinical presentation, outcomes, and prevention and management strategies to minimize the occurrence and impact of SUPC. A sample SUPC hospital policy is included in the manuscript.

Skin-to-Skin Contact and Breastfeeding After Planned Cesarean Birth Before and During the COVID-19 Pandemic

Background: Benefits of early skin-to-skin contact (SSC) between mother and newborn are widely documented, including improved breastfeeding outcomes. While promoting immediate SSC is standard practice for vaginal birth, it happens less often after cesarean birth. It is not known how changes in hospital practices and staffing shortages during the COVID-19 pandemic have influenced the practice of SSC in the operating room (OR). This study aims to identify the relationship between SSC after cesarean birth and breastfeeding and compare SSC before and during the COVID-19 pandemic at a single institution. Materials and Methods: This was a retrospective cohort study of 244 subjects who had scheduled cesarean births during 2019 and 2020. The primary outcome was newborn feeding at hospital discharge. Secondary outcomes were time to initiate breastfeeding, newborn feeding at 4-8-weeks postpartum, and location of SSC initiation in 2019 versus 2020. Results: SSC within 3 days of birth was significantly associated with feeding type on discharge and/or 4-8 weeks postpartum. More subjects intending to exclusively breastfeed met this intention at discharge with SSC in the OR. Newborns who had SSC in the OR had significantly earlier initiation of breastfeeding. There was an increase in SSC in the OR between 2019 (27%) and 2020 (39%). Conclusion: SSC in the OR was associated with improved short-term breastfeeding outcomes in our study. If immediate SSC is not possible, SSC within 3 days of birth may have breastfeeding benefits. The increase in SSC in the OR during the COVID-19 pandemic indicates that SSC practices can be implemented, despite challenging circumstances.

90 versus 60 min of early skin-to-skin contact on exclusive breastfeeding rate in healthy infants' ≥35 weeks: A randomised controlled trial

AIM

To compare the effect of 90 versus 60 min of early skin-to-skin contact (SSC) among vaginally born healthy infants ≥35 weeks of gestation on their exclusive breastfeeding rates and breastfeeding behaviour.

METHODS

This parallel-group, open-label, randomised controlled trial enrolled healthy term and late preterm infants born vaginally. Infants in the intervention group received early SSC for 90 min compared to 60 min in the control group. The primary outcome was the proportion of infants on exclusive breastfeeding at 60 ± 12 h.

RESULTS

One hundred ninety-eight mother-infant dyads were randomised (99 in each group). The infants in the 90-min SSC group were more likely to be exclusively breastfed at 60 ± 12 h as compared to the 60-min SSC group (RR, 95% CI-1.44, [1.15-1.79], p < 0.01). The modified infant breastfeeding assessment tool score at 60 ± 12 h was significantly higher in the 90-min SSC group (median [IQR]-9, [8, 10] versus 8 [7, 10], p = 0.03]. The proportion of infants on exclusive breastfeeding at 6, 10, and 14 weeks of age was also significantly higher in the 90-min SSC group (RR, 95% CI-1.39 [1.11-1.74], 1.36 [1.08-1.07], and 1.38 [1.08-1.75], respectively).

CONCLUSION

Increasing the duration of early SSC showed a dose-response benefit on exclusive breastfeeding rates and breastfeeding behaviour.

TRIAL REGISTRATION

CTRI/2018/09/015632, registered on 06/09/2018.

Skin-To-Skin Contact During Cesarean Birth in the United States over the Last Decade

PURPOSE

To assess skin-to-skin contact during cesarean birth, including incidence and maternal characteristics.

STUDY DESIGN AND METHODS

A cross-sectional, retrospective study using survey methods was conducted. Women who had a cesarean birth within the last 10 years prior to January 2022 were recruited via social media. Descriptive statistics, chi square, and binary logistic regression analyses were calculated.

RESULTS

There were 2,327 participants, of which 29.7% experienced skin-to-skin contact during their cesarean birth. This was reported to be less often than desired. Significant associations were found among skin-to-skin contact during cesarean birth and planned cesarean birth, previous cesarean birth, maternal age, level of education, and birth region. Previous vaginal birth and race were not significantly associated with skin-to-skin contact during cesarean birth. Most (93.65%) respondents identified as White. Barriers to skin-to-skin contact during cesarean birth may be birth region, unplanned or emergency cesarean births, younger age, lacking a college degree, and lack of previous cesarean births.

CLINICAL IMPLICATIONS

There are differences in incidence and access to skin-to-skin contact during cesarean birth. Our findings emphasize the continued need to address disparities in care, increase maternal health care equity, and make skin-to-skin contact during cesarean birth available for all women who desire it.

Spontaneous behaviors during breast crawling and factors influencing self-locating mothers' breasts in newborns: A cross-sectional study

Breast crawling in newborns to propel themselves to their mothers' breasts normally occurs upon skin-to-skin contact with mothers immediately after birth but is often missed by the neglect of hospital staff and insufficient evidence support. Hence, this study described the behavioral characteristics of 135 newborns from China during breast crawling and further explored the factors influencing newborns' self-locating mothers' breasts (measured by whether fail to experience the familiarization stage, initial time and duration of the familiarization stage) using multivariable analysis. The findings supported and extended previous studies that newborns could emerge in nine instinctive stages and corresponding spontaneous behaviors early in life. Moreover, abnormal fetal heart rate during labor appeared to interfere with newborns experiencing the familiarization stage (aOR = 9.27, 95% CI: 1.41 to 61.07, P = 0.021), while using synthetic oxytocin (β = 5.94, 95% CI: 0.35 to 11.54, P = 0.037), using antibiotics (β = 11.09, 95% CI: 4.11 to 18.07, P = 0.002), and newborns' gender (β = -5.69, 95% CI: 11.26 to -0.12, P = 0.045) would alter the initial time of the familiarization stage. Finally, this study proposes evidence-based strategies to prevent abnormal fetal heart rates and improve medication use.

The Effect of Breastfeeding in the First Hour and Rooming-In of Low-Income, Multi-Ethnic Mothers on In-Hospital, One and Three Month High Breastfeeding Intensity

Despite the known benefits of exclusive breastfeeding, the value of Baby-Friendly Hospital Interventions in increasing breastfeeding rates has been challenged, particularly the interventions of breastfeeding in the first hour of life and rooming-in. This study aimed to measure the association of breastfeeding in the first hour of life and rooming-in with high breastfeeding intensity of low-income, multi-ethnic mothers intending to breastfeed. A prospective, longitudinal cohort study was performed on 149 postpartum mothers who intended to breastfeed their infants. Structured interviews were performed at birth and one and three months. Breastfeeding intensity was defined as the percentage of all feedings that were breast milk, and high breastfeeding intensity was defined as a breastfeeding intensity >80%. The data were analyzed by chi-square, t-test, binary logistic regression analysis, and multivariate logistic regression analysis. Breastfeeding in the first hour was associated with increased high breastfeeding intensity in the hospital (AOR = 11.6, 95% CI = 4.7-28.6) and at one month (AOR = 3.6, 95% CI = 1.6-7.7), but not at three months. Rooming-in was associated with increased high breastfeeding intensity in the hospital (AOR 9.3, 95% CI = 3.6-23.7) and at one month (AOR = 2.4 (1.1-5.3) and three months (AOR 2.7, 95% CI 1.2-6.3). Breastfeeding in the first hour and rooming-in are associated with increasing breastfeeding and should be incorporated into practice.

Nurses' Perceptions of a Novel Rooming-in Program for Infants With Critical Congenital Heart Disease

BACKGROUND

The transition to home for infants who require complex care can be overwhelming for caregivers. Infants with critical congenital heart disease (CCHD) require advanced care management, so their caregivers must acquire extensive training before the infants are discharged home. Rooming-in programs have improved patient outcomes in other settings, such as the postpartum period. However, little research has examined a rooming-in program in a pediatric cardiac acute care setting.

OBJECTIVE

To describe nurses' perceptions of a novel rooming-in program implemented in a pediatric cardiac acute care unit.

METHODS

A qualitative descriptive research design was used to describe nurses' perceptions of the rooming-in program for infants with CCHD. Three focus groups were conducted with a convenience sample of 13 registered nurses who cared for infants with CCHD during the rooming-in program. Four trained independent coders performed qualitative thematic analysis.

RESULTS

Nurses provided critical insight into the rooming-in program. Three themes were identified: improved nursing and family outcomes, leading the way through collaboration, and room for improvement.

CONCLUSIONS

Infants with CCHD have complex needs, and caregivers must acquire advanced skills to adequately care for these infants. This study is the first to explore nurses' perceptions of a rooming-in program for infants with CCHD. The findings could improve rooming-in programs in the pediatric acute care setting, which can translate to better patient outcomes.

Safe Newborn Sleep Practices on a Large Volume Maternity Service

PURPOSE

Reinforcing safe infant sleep conditions in the hospital setting supports continuation of safe sleep practices after hospital discharge and should be considered the first line of defense for reducing risk for sudden unexpected infant death (SUID) and sudden infant death syndrome (SIDS) at home. The purpose of this study is to determine knowledge of perinatal nurses, nursing assistants, physicians, and ancillary personnel about safe sleep recommendations and implementation of safe sleep practices on the mother-baby unit.

STUDY DESIGN AND METHODS

Nurses and other members of the perinatal health care team in a level III maternity service were invited to participate in a survey about safe sleep knowledge and practices. An audit for safe sleep adherence was conducted on the mother-baby unit for 120 mother-baby couplets over 1 year as a process improvement project.

RESULTS

N = 144 surveys were completed; most participants (86%) were nurses. They had high levels of knowledge about safe sleep recommendations and 74% reported making at least one safe sleep adjustment during one shift per week. The most common modifications at least once per week were removing baby from a sleeping caregiver (30%) and removing items from baby's bassinet (26%). Safe sleep audit findings revealed 32 out of 120 couplets were not fully following safe sleep recommendations, with most common unsafe sleep practice metrics being items in the baby's bassinet (18%) and bassinets propped up (8%).

CLINICAL IMPLICATIONS

During the hospitalization for childbirth, new parents can learn about safe sleep practices from the perinatal health care team. Sharing information and role modeling safe sleep practices can promote continuation of safe sleep practices for the newborn at home after hospital discharge.

Social Interactions and Institutional Structures that Influence 24-Hour Rooming-in for New Mothers and Newborns in the Hospital Setting

PURPOSE

To describe the social interactions and institutional structures that influence the consistent practice of 24-hour rooming-in of new mothers and newborns in the hospital setting.

STUDY DESIGN AND METHOD

Using an institutional ethnographic design, data were gathered via semistructured interviews and on-unit observations. Data were recorded, transcribed, and analyzed for themes. Study interviews were conducted between February 2020 and June 2021.

RESULTS

Seven mother-baby nurses were interviewed, and three on-unit observations of 2 hours each were conducted. Analysis of interview data revealed a consensus that Baby-Friendly does not always feel mother-friendly. Three major themes identifying social interactions were identified: the mother as a patient, managing expectations, and inconsistencies in practice. Three themes identified institutional structures that influenced 24-hour rooming-in: rates of induction of labor and cesarean birth, nurse staffing, and monitoring of nursery use.

CLINICAL IMPLICATIONS

Our findings provide insights about how the everyday work of 24-hour rooming-in is organized and experienced by nurses on the mother-baby units at the study hospital. Themes highlight specific social interactions and institutional structures that affect the practice and can be used by hospital leaders and educators to develop targeted interventions for ensuring consistent 24-hour rooming-in.

Care of the Well Newborn

Care of the newborn infant is a critical skill for general pediatricians and other providers in the practice of pediatric medicine. Optimal care relies on a thorough understanding of risk factors that may be present during the pregnancy and delivery, as well as the ability to recognize and address unanticipated problems in the postnatal period. This article focuses on antenatal care of the newborn, issues that present in the immediate postdelivery period, and care of the newborn after discharge. It also includes updated information on current topics in pediatric practice, such as the importance of vaccination, parental hesitancy in accepting common medical interventions, and updated guidelines related to the coronavirus disease 2019 pandemic. At the conclusion of the article, the reader should have a general understanding of antenatal risk factors that could affect the transition from the intrauterine environment and have the knowledge to address common issues that arise in the care of newborn infants.

Sudden unexpected infant death risk profiles in the first month of life

BACKGROUND

Limited improvement in current SUID rates requires further identification of its characteristics, including age-specific risk patterns.

OBJECTIVE

Compare SUID risk factors in the first week versus the remainder in the first month of life.

DESIGN/METHODS

We compared maternal and infant data from New Jersey databases for SUID from 2000 to 2015 in infants ≥ 34 weeks GA in the two groups.

RESULTS

In the period studied, 123 died in the first 27 days, 24 before seven. Deaths in the first week had a higher percentage of mothers with post-High School education (OR 3.50, CI: 1.38-8.87) and a primary Cesarean section delivery (OR 4.0, CI: 1.39-11.49), and a smaller percentage with inadequate prenatal care (OR 0.36, CI: 0.14, 0.94). A smaller percentage of first-week deaths had mothers who smoked during pregnancy or identified as Black, non-Hispanic, but these findings did not reach significance (p < .08 and p < .09, respectively).

CONCLUSIONS

SUID in the first week and the first month of life is rare. However, despite a limited sample size, data suggest that even within the first month of life, there are differences in risk patterns for SUID based on age at death. Age-specific profiles may lead to new hypotheses regarding causality and more refined risk-reduction guidelines and warrant further study.

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.

Quality improvement initiative to improve infant safe sleep practices in the newborn nursery

The American Academy of Pediatrics recommends that healthcare professionals model their safe infant sleeping environment recommendations, yet adherence to safe sleep practices within our community hospital mother–baby unit was low. We used quality improvement (QI) methodology to increase adherence to infant safe sleep practices, with a goal to improve the proportion of infants sleeping in an environment that would be considered ‘perfect sleep’ to 70% within a 1-year period. The project occurred while the hospital was preparing for Baby Friendly certification, with increased emphasis on rooming in and skin to skin at the same time.

Multiple Plan–Do–Study–Act cycles were performed. Initial cycles targeted nurse and parental education, while later cycles focused on providing sleep sacks/wearable blankets for the infants.

While we did not meet our goal, the percentage of infants with ‘perfect sleep’ increased from a baseline of 41.9% to 67.3%, and we also saw improvement in each of the individual components that contribute to this composite measure. Improvements were sustained over 12 months later, suggesting that QI interventions targeting infant safe sleep in this inpatient setting can have long-lasting results. This project also suggests that infant safe sleep QI initiatives and preparation towards Baby Friendly Hospital Certification can be complementary.

Use of a Quality Scorecard to Enhance Quality and Safety in Community Hospital Newborn Nurseries

OBJECTIVE

To implement a quality improvement (QI) scorecard as a tool for enhancing quality and safety efforts in level 1 and 2 community hospital nurseries affiliated with Nationwide Children's Hospital.

STUDY DESIGN

A QI scorecard was developed for data collection, analytics, and reporting of neonatal quality metrics and cross-sector collaboration. Newborn characteristics were included for risk stratification, as were clinical and process measures associated with neonatal morbidity and mortality. Quality and safety activities took place in community hospital newborn nurseries in Ohio, and education was provided in both online and in-person collaborations, followed by local team sessions at partner institutions. Baseline (first 12 months) and postbaseline comparisons of clinical and process measures were analyzed by logistic regression, adjusting for potential confounders.

RESULTS

In logistic regression models, at least 1 center documented improvements in each of the 4 process measures, and 3 of the 4 centers documented improvements in compliance with glucose checks obtained within 90 minutes of birth among at-risk infants.

CONCLUSION

Collaborative QI projects led to improvements in perinatal metrics associated with important outcomes. Formation of a center-driven QI scorecard is feasible and provides community hospitals with a framework for collecting, analyzing, and reporting neonatal QI metrics.

Evidence Base for 2022 Updated Recommendations for a Safe Infant Sleeping Environment to Reduce the Risk of Sleep-Related Infant Deaths

Every year in the United States, approximately 3500 infants die of sleep-related infant deaths, including sudden infant death syndrome (SIDS) (International Statistical Classification of Diseases and Related Health Problems 10th Revision [ICD-10] R95), ill-defined deaths (ICD-10 R99), and accidental suffocation and strangulation in bed (ICD-10 W75). After a substantial decline in sleep-related deaths in the 1990s, the overall death rate attributable to sleep-related infant deaths have remained stagnant since 2000, and disparities persist. The triple risk model proposes that SIDS occurs when an infant with intrinsic vulnerability (often manifested by impaired arousal, cardiorespiratory, and/or autonomic responses) undergoes an exogenous trigger event (eg, exposure to an unsafe sleeping environment) during a critical developmental period. The American Academy of Pediatrics recommends a safe sleep environment to reduce the risk of all sleep-related deaths. This includes supine positioning; use of a firm, noninclined sleep surface; room sharing without bed sharing; and avoidance of soft bedding and overheating. Additional recommendations for SIDS risk reduction include human milk feeding; avoidance of exposure to nicotine, alcohol, marijuana, opioids, and illicit drugs; routine immunization; and use of a pacifier. New recommendations are presented regarding noninclined sleep surfaces, short-term emergency sleep locations, use of cardboard boxes as a sleep location, bed sharing, substance use, home cardiorespiratory monitors, and tummy time. In addition, additional information to assist parents, physicians, and nonphysician clinicians in assessing the risk of specific bed-sharing situations is included. The recommendations and strength of evidence for each recommendation are published in the accompanying policy statement, which is included in this issue.

Infant Safe Sleep Initiative in a Small Volume Maternity Service

PURPOSE

Despite the 2016 American Academy of Pediatrics recommendations for preventing sudden unexpected infant death, there are approximately 3,400 sudden unexpected infant deaths annually in the United States. Modeling of safe sleep practices by nurses in the hospital influences parents' practice at home; however, safe sleep practices are not consistently modeled during the childbirth hospitalization.

METHODS

A quality improvement project was conducted to implement a safe sleep initiative based on the 2016 American Academy of Pediatrics recommendations for nurses caring for hospitalized infants after birth. Evaluation included testing of nurses' knowledge, infant crib audits, and nurses' evaluation of the intervention.

RESULTS

A significant improvement was found in overall nurse education scores. Crib audits demonstrated a significant improvement in the following elements: use of multiple blankets, swaddling of the infant, and parent teaching. Nursing surveys reported an increase in confidence to practice safe sleep recommendations and educate and redirect parents.

CLINICAL IMPLICATIONS

Implementing a safe sleep initiative can increase nurses' knowledge, improve adherence to recommendations with modeling safe sleep practices, and increase parent awareness of safe sleep recommendations, potentially positively affecting adherence after discharge.

Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment

Each year in the United States, ∼3500 infants die of sleep-related infant deaths, including sudden infant death syndrome (SIDS) (International Classification of Diseases, 10th Revision [ICD-10] R95), ill-defined deaths (ICD-10 R99), and accidental suffocation and strangulation in bed (ICD-10 W75). After a substantial decline in sleep-related deaths in the 1990s, the overall death rate attributable to sleep-related infant deaths has remained stagnant since 2000, and disparities persist. The triple risk model proposes that SIDS occurs when an infant with intrinsic vulnerability (often manifested by impaired arousal, cardiorespiratory, and/or autonomic responses) undergoes an exogenous trigger event (eg, exposure to an unsafe sleeping environment) during a critical developmental period. The American Academy of Pediatrics recommends a safe sleep environment to reduce the risk of all sleep-related deaths. This includes supine positioning; use of a firm, noninclined sleep surface; room sharing without bed sharing; and avoidance of soft bedding and overheating. Additional recommendations for SIDS risk reduction include human milk feeding; avoidance of exposure to nicotine, alcohol, marijuana, opioids, and illicit drugs; routine immunization; and use of a pacifier. New recommendations are presented regarding noninclined sleep surfaces, short-term emergency sleep locations, use of cardboard boxes as a sleep location, bed sharing, substance use, home cardiorespiratory monitors, and tummy time. Additional information to assist parents, physicians, and nonphysician clinicians in assessing the risk of specific bed-sharing situations is also included. The recommendations and strength of evidence for each recommendation are included in this policy statement. The rationale for these recommendations is discussed in detail in the accompanying technical report.

Technical Report: Breastfeeding and the Use of Human Milk

Breastfeeding and human milk are the normative standards for infant feeding and nutrition. The short- and long-term medical and neurodevelopmental advantages of breastfeeding make breastfeeding or the provision of human milk a public health imperative. The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for approximately 6 months after birth. Furthermore, the AAP supports continued breastfeeding, along with appropriate complementary foods introduced at about 6 months, as long as mutually desired by mother and child for 2 years or beyond. These recommendations are consistent with those of the World Health Organization (WHO). Medical contraindications to breastfeeding are rare. The AAP recommends that birth hospitals or centers implement maternity care practices shown to improve breastfeeding initiation, duration, and exclusivity. The Centers for Disease Control and Prevention and The Joint Commission monitor breastfeeding practices in United States hospitals. Pediatricians play a critical role in hospitals, their practices, and communities as advocates of breastfeeding and, thus, need to be trained about the benefits of breastfeeding for mothers and children and in managing breastfeeding. Efforts to improve breastfeeding rates must acknowledge existing disparities and the impact of racism in promoting equity in breastfeeding education, support, and services.

Policy Statement: Breastfeeding and the Use of Human Milk

Breastfeeding and human milk are the normative standards for infant feeding and nutrition. The short- and long-term medical and neurodevelopmental advantages of breastfeeding make breastfeeding, or the provision of human milk, a public health imperative. The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for approximately 6 months after birth. Furthermore, the AAP supports continued breastfeeding, along with appropriate complementary foods introduced at about 6 months, as long as mutually desired by mother and child for 2 years or beyond. These recommendations are consistent with those of the World Health Organization (WHO). Medical contraindications to breastfeeding are rare. The AAP recommends that birth hospitals or centers implement maternity care practices shown to improve breastfeeding initiation, duration, and exclusivity. The Centers for Disease Control and Prevention (CDC) and The Joint Commission monitor breastfeeding practices in US hospitals. Pediatricians play a critical role in hospitals, their practices, and communities as advocates of breastfeeding and, thus, need to be trained about the benefits of breastfeeding for mothers and children and in managing breastfeeding.

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

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

Análisis de Costo Efectividad del Contacto Piel a Piel al Nacimiento, Temprano vs Inmediato, en la Morbilidad Neonatal de Recién Nacidos de Bajo Riesgo

OBJECTIVES

This study aimed to evaluate the cost-effectiveness of immediate skin-to-skin contact compared with early skin-to-skin contact in the prevalent neonatal morbidity of the low-risk newborn in Colombia.

METHODS

A cost-effectiveness analysis was conducted. The perspective of the third payer (health system) was used, and the time horizon was the first month of life. Low-risk term infants were included at birth. The cost estimate was obtained from an expert consensus and a retrospective cohort of neonates hospitalized in a neonatal unit. The effectiveness of the interventions was obtained from a clinical trial and was defined as an avoided case of hospitalization. A decision tree was built, and the incremental cost-effectiveness ratio was calculated. Deterministic and probabilistic sensitivity analyses of the effects and costs were performed.

RESULTS

Early skin-to-skin contact was a dominated intervention. In the probabilistic sensitivity analyses, early skin-to-skin contact was not an option to choose in any scenario and it was dominated in 68% of the simulations.

CONCLUSIONS

The findings suggest that early skin-to-skin contact is a dominated intervention. From an economic perspective, immediate skin-to-skin contact is a desired intervention for the prevention of prevalent diseases of the low-risk newborn at birth.

Maternal and Neonatal Prognostic Factors for Cardiorespiratory Events in Healthy Term Neonates During Early Skin-to-Skin Contact

BACKGROUND

During early skin-to-skin contact (ESSC), alterations in peripheral oxygen saturation (SpO₂) and heart rate (HR) have been frequently observed.

OBJECTIVES

This study aimed to determine the incidence of cardiorespiratory events (CREs) during ESSC in healthy term newborns (HTNs) and estimate the association of maternal and neonatal prognostic factors with the risk of CREs.

METHODS

A pooled analysis of the cohort from a clinical trial involving healthy mother-child dyads during ESSC was performed. Pulse oximetry was employed to continuously monitor SpO₂ and HR within 2 h after birth. The individual and combined prognostic relevance of the demographic and clinical characteristics of dyads for the occurrence of a CRE (SpO₂ <91% or HR <111 or >180 bpm) was analyzed through logistic regression models.

RESULTS

Of the 254 children assessed, 169 [66.5%; 95% confidence interval (95% CI), 60.5-72.5%] had at least one CRE. The characteristics that increased the risk of CRE were maternal age ≥35 years (odds ratio, 2.21; 95% CI, 1.19-4.09), primiparity (1.96; 1.03-3.72), gestational body mass index (BMI) >25 kg/m² (1.92; 1.05-3.53), and birth time between 09:00 p.m. and 08:59 a.m. (2.47; 1.02-5.97).

CONCLUSION

CREs were more frequent in HTNs born during nighttime and in HTNs born to first-time mothers, mothers ≥35 years, and mothers with a gestational BMI >25 kg/m². These predictor variables can be determined during childbirth. Identification of neonates at higher risk of developing CREs would allow for closer surveillance during ESSC.

Twenty Years Baby-Friendly: Personal Reflections on Change

Background: Boston Medical Center (BMC) is an inner-city hospital located in Boston, Massachusetts. In 1995, like many maternity hospitals in the United States, BMC had policies that routinely separated mothers from their babies, limited breastfeeding education for staff, provided no hospital-funded lactation consultants, and did not initiate any limitations on the presence of the formula industry in the hospital. This all changed in 1999 when BMC became the first Baby-Friendly designated hospital in Massachusetts and the 22^nd in the nation. Objective: Describe challenges encountered on the hospital's journey to Baby-Friendly and subsequent re-designations and share strategies used to overcome them. Materials and Methods: Policy changes and new programs instituted over the twenty-year period are described as well as personal reflections on change by the author. Results: Over the time period chronicled, improvements in breastfeeding initiation and exclusivity rates were observed. From 1997 to 2019, the breastfeeding initiation rate increased from 53% to 90% and the exclusive breastfeeding rate increased from 6% to 50-60%. Delivery volume at the hospital increased from 1600 to 2850 births per year in the same time period. Following the Ten Steps is an important way to decrease racial disparity gaps. Conclusions: Change is possible in the hospital setting. Achieving and maintaining Baby-Friendly designation is a successful strategy to increase maternity unit breastfeeding rates.

Breastfeeding Insufficiencies: Common and Preventable Harm to Neonates

Insufficient milk intake in breastfed neonates is common, frequently missed, and causes preventable hospitalizations for jaundice/hyperbilirubinemia, hypernatremia/dehydration, and hypoglycemia - accounting for most U.S. neonatal readmissions. These and other consequences of neonatal starvation and deprivation may substantially contribute to fully preventable morbidity and mortality in previously healthy neonates worldwide. Previous advanced civilizations recognized this problem of breastfeeding insufficiencies and had an infrastructure to solve it: Wetnursing, shared nursing, and prelacteal feeding traditions used to be well-organized and widespread. Modern societies accidentally destroyed that infrastructure. Then, modern reformers missing a few generations of direct knowledge transmission about safe breastfeeding invented a new, historically anomalous conception of breastfeeding defined in terms of exclusivity. As that new intervention has become increasingly widespread, so too have researchers widely reported associated possible harms of the longer neonatal starvation/deprivation and later infant under-nutrition periods that it creates when breastfeeding is insufficient. Early insufficient nutrition/hydration has possible long-term effects including neurodevelopmental consequences such as attention deficit hyperactivity disorder, autism, cerebral palsy, cognitive and developmental delay, epilepsy, hearing impairment, kernicterus, language disorder, mood disorders, lower IQ, and specific learning disorder. Current early infant feeding guidelines conflict with the available evidence. Recent reform efforts have tended to focus on using more technology and measurement to harm fewer neonates instead of proposing the indicated paradigm shift in early infant feeding to prevent more harm. The scientific evidence is already sufficient to mandate application of the precautionary principle to feed neonates early, adequate, and often milk before mothers' milk comes in and whenever signs of hunger persist, mitigating possible risks including death or disability. In most contexts, the formula is the best supplementary milk for infants at risk from breastfeeding insufficiencies. National-level reviews of scientific evidence, health policy, and research methods and ethics are needed to initiate the early infant feeding paradigm shift that the data already support. Policy experiments and related legislative initiatives might also contribute to the shift, as insurers might decline or be required by law to decline reimbursing hospitals for costs of this type of preventable hospitalization, which otherwise generates profit.

ABM Clinical Protocol #35: Supporting Breastfeeding During Maternal or Child Hospitalization

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. The Academy of Breastfeeding Medicine recognizes that not all lactating individuals identify as female. Using gender-inclusive language, however, is not possible in all languages and all countries and for all readers. The position of the Academy of Breastfeeding Medicine (https://doi.org/10.1089/bfm.2021.29188.abm) is to interpret clinical protocols within the framework of inclusivity of all breastfeeding, chestfeeding, and human milk-feeding individuals.

Sudden Unexpected Infant Death: Keeping the Newborn Safe in Hospital and at Home

Sudden unexpected infant death is a leading cause of death in infancy. Both safe sleep practices and breastfeeding can help decrease the risk, although the current practice of educating parents about the recommendations has not resulted in universal adherence. Prenatal counseling provides opportunities to discuss recommendations as well as troubleshoot common barriers to breastfeeding and safe infant sleep with goals to gradually change attitudes, address social norms, and prepare new parents. A conversational, motivational approach to discussions about the importance of safe sleep and continued breastfeeding, with explanations as to the reasoning behind these recommendations, can help parents incorporate optimal practices into their lifestyles in a way that is sustainable for adherence.

Transition to a Safe Home Sleep Environment for the NICU Patient

Of the nearly 3.8 million infants born in the United States in 2018, 8.3% had low birth weight (ie, weight <2500 g) and 10% were born preterm (ie, gestational age of <37 weeks). Ten to fifteen percent of infants (approximately 500 000 annually), including low birth weight and preterm infants and others with congenital anomalies, perinatally acquired infections, and other diseases, require admission to a NICU. Every year, approximately 3600 infants in the United States die of sudden unexpected infant death (SUID), including sudden infant death syndrome (SIDS), unknown and undetermined causes, and accidental suffocation and strangulation in an unsafe sleep environment. Preterm and low birth weight infants are 2 to 3 times more likely than healthy term infants to die suddenly and unexpectedly. Thus, it is important that health care professionals prepare families to maintain their infant in a safe home sleep environment as per recommendations of the American Academy of Pediatrics. Medical needs of the NICU infant often require practices such as nonsupine positioning, which should be transitioned as soon as medically possible and well before hospital discharge to sleep practices that are safe and appropriate for the home environment. This clinical report outlines the establishment of appropriate NICU protocols for the timely transition of these infants to a safe home sleep environment. The rationale for these recommendations is discussed in the accompanying technical report "Transition to a Safe Home Sleep Environment for the NICU Patient," included in this issue of Pediatrics.

Transition to a Safe Home Sleep Environment for the NICU Patient

Of the nearly 3.8 million infants born in the United States in 2018, 8.3% had low birth weight (<2500 g [5.5 lb]) and 10% were born preterm (gestational age of <37 completed weeks). Many of these infants and others with congenital anomalies, perinatally acquired infections, and other disease require admission to a NICU. In the past decade, admission rates to NICUs have been increasing; it is estimated that between 10% and 15% of infants will spend time in a NICU, representing approximately 500 000 neonates annually. Approximately 3600 infants die annually in the United States from sleep-related deaths, including sudden infant death syndrome International Classification of Diseases, 10th Revision (R95), ill-defined deaths (R99), and accidental suffocation and strangulation in bed (W75). Preterm and low birth weight infants are particularly vulnerable, with an incidence of death 2 to 3 times greater than healthy term infants. Thus, it is important for health care professionals to prepare families to maintain their infant in a safe sleep environment, as per the recommendations of the American Academy of Pediatrics. However, infants in the NICU setting commonly require care that is inconsistent with infant sleep safety recommendations. The conflicting needs of the NICU infant with the necessity to provide a safe sleep environment before hospital discharge can create confusion for providers and distress for families. This technical report is intended to assist in the establishment of appropriate NICU protocols to achieve a consistent approach to transitioning NICU infants to a safe sleep environment as soon as medically possible, well before hospital discharge.

Skin-to-Skin Care Practice and Its Associated Factors Among Postpartum Mothers in Gurage Zone, Southern Ethiopia: A Cross-Sectional Study

Background

Skin-to-skin care is placing an unclothed or diaper-only newborn baby on the mother’s bare chest, covered with a warm blanket. The World Health Organization recommends immediate, uninterrupted, and continuous mother–newborn skin-to-skin care practice almost immediately after birth. Despite this recommendation, separation of the newborn from the mother is common in many public health institutions. There was a limited study that examined the prevalence of skin-to-skin care practice and associated factors in Ethiopia. Therefore, the main aim of this study was to assess the prevalence of skin-to-skin care practice and its associated factors among postpartum mothers in Gurage Zone public health centers, Southern Ethiopia, 2020.

Methods

An institution-based cross-sectional study was conducted in twenty-two public health centers of Gurage Zone from January 1st up to 30th, 2020. A total of 382 postpartum mothers were selected using a systematic sampling technique. Data were collected using structured and pre-tested interviewer-administered questionnaires. Data were entered into EpiData version 3.1.0 and exported to SPSS version 23 for analysis. Both bivariable and multivariable logistic regression analyses were used to identify significant factors associated with skin-to-skin care practice. Statistical significance was declared at a P-value of <0.05 with a 95% confidence level.

Results

About 35.3% (95% CI; 31.3%–40.4%) of new-borns were received skin-to-skin care practice. Being urban residence [AOR=2.23, (95% CI; 1.17–4.23)], normal newborn birth weight (≥2500gm) [AOR=3.1, (95% CI; 2.15–3.89)], early initiation of breastfeeding [AOR=2.93, (95% CI; 1.29–6.64)], colostrum feeding [AOR=4.19, (95% CI; 2.01–8.73)], and having mothers good knowledge on skin-to-skin care practice [AOR=8.51, (95% CI; 4.32–16.75)] were some of factors associated with mother to newborn skin-to-skin care practice.

Conclusion

The proportion of mother newborn skin-to-skin care practice was low in the study area. Mothers resided in the urban areas, normal newborn birth weight, early initiation of breastfeeding, colostrum feeding, and having good knowledge of the mothers about skin-to-skin care were factors associated with skin-to-skin care practice. Therefore, health care workers should counsel mothers on optimal breastfeeding practice and enhance maternal awareness regarding the merits of skin-to-skin care practice before discharge from the health facilities are recommended.

Missed Nursing Care During Labor and Birth and Exclusive Breast Milk Feeding During Hospitalization for Childbirth

PURPOSE

The purpose of this study was to determine associations between missed nursing care and nurse staffing during labor and birth, and exclusive breast milk feeding at hospital discharge.

STUDY DESIGN AND METHODS

Labor and birth nurses in three states were surveyed about missed nursing care and their maternity units' adherence to the AWHONN (2010) nurse staffing guidelines for care during labor and birth, using the Perinatal Misscare Survey. Nursing responses were aggregated to the hospital level and estimated associations between missed nursing care, nurse staffing, and hospitals' exclusive breast milk feeding rates were measured using The Joint Commission's Perinatal Care Measure (PC-05).

RESULTS

Surveys from 512 labor nurses in 36 hospitals were included in the analysis. The mean exclusive breast milk feeding rate was 53% (range 13%-76%). Skin-to-skin care, breastfeeding within 1 hour of birth, and appropriate recovery care were on average occasionally missed (2.33 to 2.46 out of 4; 1 = rarely, 2 = occasionally, 3 = frequently, or 4 = always) and were associated with PC-05 [B(CI) -17.1(-29, -6.3), -17.9(-30.5, -6.2), and -15.4(-28.7, -2.1), respectively]. Adherence with overall staffing guidelines was associated with PC-05 [12.9(3.4, 24.3)]. Missed nursing care was an independent predictor of PC-05 [-14.6(-26.4, -2.7)] in a multilevel model adjusting for staffing guideline adherence, perceived quality, mean age of respondents, and nurse burnout.

CLINICAL IMPLICATIONS

Exclusive breast milk feeding is a national quality indicator of inpatient maternity care. Nurses have substantial responsibility for direct support of infant feeding during the childbirth hospitalization. These results support exclusive breast milk feeding (PC-05) as a nurse-sensitive quality indicator.

Heart-rate agreement between ECG and a new, wireless device during early skin-to-skin contact

AIM

To assess the agreement of heart rate (HR) between the new device - a fabric jacket for neonates, with integrated sensors detecting ECG signals and a Bluetooth connection to a computer (ComfTech, HOWDY) - and the clinical reference, ECG, during the skin-to-skin contact (SSC) in the first 2 h after birth, for the potential use of early detection of Sudden and Unexpected Postnatal Collapse (SUPC).

METHODS

We enrolled newborns ≥35⁺⁰  weeks of gestation, with Apgar score >8 at 5 min in a prospective, observational study in the delivery room, excluding infants with need for resuscitation, clinical instability or major malformations. We assessed HR within 20 min after birth by both devices simultaneously: the index test ComfTech HOWDY and the standard ECG (Vita Guard VG 3100, Getemed). We compared HR between the two methods at 0, 15, 30, 45, 60, 90 and 120 min by the Bland-Altman plot.

RESULTS

We included 60 infants. The mean difference between the methods was -1.3 bpm, 95%LoA -12.4 to 9.7 bpm. Spearman rank correlation coefficient ρ = -0.06.

CONCLUSION

ComfTech HOWDY presents reliable agreement with the ECG and might assist in identifying infants at risk for SUPC.

A Survey of Neonatal Clinicians' Use, Needs, and Preferences for Kangaroo Care Devices

BACKGROUND

Decades of research supports the benefits of kangaroo care (KC) for the parent and newborn. Supportive KC devices may be an important tool clinicians can use to assist parents with KC. In recent years, there has been a rise in the availability of KC devices. However, the use, needs, and preferences for these supportive devices by neonatal clinicians have not been documented.

PURPOSE

To survey clinicians' use, needs, and preferences of KC supportive devices, and examine whether differences exist based on clinician and organizational characteristics.

METHODS

A cross-sectional, online survey was sent through neonatal organization Web sites, conferences, and social media.

RESULTS

Many clinicians (n = 68, 43%; N = 158) facilitated KC with a supportive device, with 81% of devices provided by the clinician's employer. The most important "Must Have" feature of a KC device was "Safety: Reduces patient falls if caregiver sleeps or needs to use hands" (84% of respondents) followed by washability (82%), and "immediate, effective access to the baby" (78%). Clinicians' responses did not differ based on hospital setting, type of unit, KC experience, or experience using a KC device.

IMPLICATIONS FOR PRACTICE

To support safe use of KC devices in neonatal intensive care unit (NICU) clinical care, a device must hold the proper KC position consistently, allow immediate access to the infant, and hold the infant in place without the parent's hands to prevent falls. Training is needed to ensure safe device use.

IMPLICATIONS FOR RESEARCH

Future research should evaluate the safety, efficacy, and cost-effectiveness of these devices.

Sudden Unexpected Postnatal Collapse Resulting in Newborn Death in the United States

BACKGROUND

The sudden collapse of an apparently healthy newborn, or sudden unexpected postnatal collapse (SUPC) is fatal in about half of cases. Epidemiological characteristics of sudden unexpected infant death (SUID) in the first week of life differ from those in the postperinatal age group (7-365 days).

AIM

To describe the characteristics of SUPC resulting in neonatal death.

METHODS

We analyzed the Centers for Disease Control and Prevention Birth Cohort Linked Birth/Infant Death Data Set (2003-2013: 41,125,233 births and 37,624 SUIDs). SUPC was defined as infants born ≥35 weeks gestational age, with a 5-minute Apgar score of ≥7, who died suddenly and unexpectedly in the first week of life.

RESULTS

Of the 37,624 deaths categorized as SUID during the study period, 616 met the SUPC criteria (1.5/100,000 live births). Eleven percent occurred on the first day of life and nearly three quarters occurred during postnatal days 3-6. SUPC deaths differed statistically from SUID deaths occurring 7-364 days of age, in particular for sex, marital status, and live birth order.

IMPLICATIONS

These data support the need for adequate nurse staffing during the immediate recovery period and for the entire postpartum stay as well as nurse rounding for new mothers in the hospital setting.

Continuous pulse oximetry during skin-to-skin care: An Australian initiative to prevent sudden unexpected postnatal collapse

AIM

To examine the use of continuous pulse oximetry monitoring (CPOM) of newborns as a non-invasive and non-intrusive standard of care for promoting early and safe skin-to-skin contact between mothers and newborns immediately after birth and to gather acceptability feedback from midwifery staff and mothers.

METHODS

All babies receiving skin-to-skin contact (SSC) had continuous pulse oximetry monitoring (CPOM) for the first-hour postbirth. Staff were trained with education sessions before implementation. Midwives and mothers were surveyed post-implementation and again after distribution of an education brochure regarding CPOM.

RESULTS

Seventy per cent of midwives and 66% of mothers responded to the survey. The majority of midwives received the practice positively and felt reassured by the use of CPOM in the immediate postpartum period. The survey identified gaps in maternal knowledge of the risk and benefits of SSC which improved significantly after the distribution of the educational brochure (P = .01).

CONCLUSION

Continuous pulse oximetry monitoring with a compact monitor in the first-hour postbirth is a simple, non-invasive and innovative approach to enhance safe skin-to-skin care by improving vigilance of newborns. Our study confirmed the acceptance of such approach by midwives and mothers in our population.

Maternal and Infant Outcomes Associated with Maternity Practices Related to COVID-19: The COVID Mothers Study

Background: Maternity care practices such as skin-to-skin care, rooming-in, and direct breastfeeding are recommended, but it is unclear if these practices increase the risk of clinically significant COVID-19 in newborns, and if disruption of these practices adversely affects breastfeeding. Methods: We performed a retrospective cohort study of 357 mothers and their infants <12 months who had confirmed or suspected COVID-19. Subjects came from an anonymous worldwide online survey between May 4 and September 30, 2020, who were recruited through social media, support groups, and health care providers. Using multivariable logistic regression, Fisher's exact test, and summary statistics, we assessed the association of skin-to-skin care, feeding, and rooming-in with SARS-CoV-2 outcomes, breastfeeding outcomes, and maternal distress. Results: Responses came from 31 countries. Among SARS-CoV-2+ mothers whose infection was ≤3 days of birth, 7.4% of their infants tested positive. We found a nonsignificant decrease in risk of hospitalization among neonates who roomed-in, directly breastfed, or experienced uninterrupted skin-to-skin care (p > 0.2 for each). Infants who did not directly breastfeed, experience skin-to-skin care, or who did not room-in within arms' reach, were significantly less likely to be exclusively breastfed in the first 3 months, adjusting for maternal symptoms (p ≤ 0.02 for each). Nearly 60% of mothers who experienced separation reported feeling "very distressed," and 29% who tried to breastfeed were unable. Presence of maternal symptoms predicted infant transmission or symptoms (adjusted odds ratio = 4.50, 95% confidence interval = 1.52-13.26, p = 0.006). Conclusion: Disruption of evidence-based quality standards of maternity care is associated with harm and may be unnecessary.

Post-Partum Skin-to-Skin Care and Infant Safety: Results of a State-Wide Hospital Survey

Objectives. Survey current experience with Skin to Skin care (SSC) in Pennsylvania Maternity Centers. Study Design. The nursing director of each Maternity Center in PA (n = 95) was sent an on-line confidential survey querying SSC practices. Responses were compared by delivery size, location, and nature of affiliation. Statistics analyzed by chi-square and student t-test. Results. Of these 64/95 MCs (67%) responded. All allowed SSC after vaginal deliveries, 55% after C-section, 73% mother's room. Monitoring included delivery room nurse (94%) with support from other providers (61%), family members (37%), and electronic monitoring (5%). If SSC occurred in mother's room all reported family education on safe practices. 40% were aware of adverse SSC events, including falls and suffocation. About 80% educated staff about infant safety during SSC. Conclusions. Gaps in education and supervision during SSC were identified. Additional education and standardization of best practices are needed to reduce risks from falls and suffocation during SSC.

Mother's Bed Incline and Desaturation Episodes in Healthy Term Newborns during Early Skin-to-Skin Contact: A Multicenter Randomized Controlled Trial

INTRODUCTION

Early skin-to-skin contact (ESSC) is associated with rare, sudden, unexpected postnatal collapse episodes. Placing the newborn in ESSC closer to an upright position may reduce the risk of airway obstruction and improve respiratory mechanics. This study assessed whether a greater inclination of the mother's bed during ESSC would reduce the proportion of healthy term newborns (HTNs) who experienced episodes of pulse oximeter saturation (SpO2) <91%.

METHODS

We conducted a multicenter randomized controlled trial comparing the effect of the mother's bed incline, 45° versus 15°, on desaturation in HTNs during ESSC. Before delivery on 1,271 dyads, randomization was conducted, and stringent criteria to select healthy mothers and term newborns were monitored until after birth. Preductal SpO2 was continuously monitored between 10 min and 2 h after birth. The primary outcome was the occurrence of at least one episode of SpO2 <91%.

RESULTS

254 (20%) mother-infant dyads were eligible for analysis (45°, n = 126; 15°, n = 128). Overall, 57% (95% confidence interval [CI]: 51%-63%) of newborns showed episodes of SpO2 <91%. The proportion of infants with SpO2 <91% episodes was 52% in 45° and 62% in 15° (relative risk: 0.80; 95% CI: 0.6-1.07).

CONCLUSIONS

We did not show that a high mother bed inclination during ESSC led to significantly fewer HTNs who experienced episodes of SpO2 <91%. Desaturation episodes from 10 min to 2 h after birth occurred in more than half of HTNs.

Short-Term Outcomes following Standardized Admission of Late Preterm Infants to Family-Centered Care

OBJECTIVE

The study compares the short-term outcomes of late preterm infants (LPI) at an academic center in San Diego, California after a change in protocol that eliminated a previously mandatory 12-hour neonatal intensive care unit (NICU) observation period after birth.

STUDY DESIGN

This is a retrospective observational study examining all LPI born with gestational age 35 to 36^6/7 weeks between October 1, 2016 and October 31, 2017. A total of 189 infants were included in the review. Short-term outcomes were analyzed before and after the protocol change.

RESULTS

Transfers to the NICU from family-centered care (FCC) were considerably higher (23.2%) following the protocol change, compared to before (8.2%). More infants were transferred to the NICU for failed car seat tests postprotocol compared to preprotocol. Length of stay before the protocol change was 5.13 days compared to 4.80 days after.

CONCLUSION

LPI are vulnerable to morbidities after delivery and through discharge. We found an increase in failed car seat tests in LPI cared for in FCC after elimination of a mandatory NICU observation after birth. The transitions of care from delivery to discharge are key checkpoints in minimizing complications.