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Qin Y, Liu S, Yang Y, Zhong Y, Hao D, Han H. Effects of human milk odor stimulation on feeding in premature infants: a systematic review and meta-analysis. Sci Rep 2024; 14:8964. [PMID: 38637563 PMCID: PMC11026474 DOI: 10.1038/s41598-024-59175-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 04/08/2024] [Indexed: 04/20/2024] Open
Abstract
Previous studies suggested odor stimulation may influence feeding of premature neonates. Therefore, this systematic review and meta-analysis of randomized controlled trials was conducted to assess the effect of human milk odor stimulation on feeding of premature infants. All randomized controlled trials related to human milk odor stimulation on feeding in premature infants published in PubMed, Cochrane, Library, Medline, Embase, Web of science databases and Chinese biomedical literature databases, China National Knowledge Infrastructure, China Science and Technology Journal Database (VIP) and Wanfang Chinese databases were searched, and The Cochrane Handbook 5.1.0 was used to evaluate the quality and authenticity of the literature. Relevant information of the included studies was extracted and summarized, and the evaluation indexes were analyzed using ReviewManager5.3. The retrieval time was from the establishment of the database to July 28, 2022.12 articles were assessed for eligibility, and six randomized controlled studies were eventually included in the meta-analysis (PRISMA). A total of 6 randomized controlled studies with 763 patients were finally included in the study, and the quality evaluation of literatures were all grade B. Human milk odor stimulation reduced the transition time to oral feeding in premature infants [SMD = - 0.48, 95% CI (- 0.69, - 0.27), Z = 4.54, P < 0.00001] and shortened the duration of parenteral nutrition [MD = - 1.01, 95% CI (- 1.70, - 0.32), Z = 2.88, P = 0.004]. However, it did not change the length of hospitalization for premature infants [MD = - 0.03, 95% CI (- 0.41, 0.35), Z = 0.17, P = 0.86]. The implementation of human milk odor stimulation can reduce the transition time to oral feeding and the duration of parenteral nutrition in premature infants, but further studies are needed to determine whether it can reduce the length of hospital stay in premature infants. More high-quality, large-sample studies are needed to investigate the effect of human milk odor stimulation on the feeding process and other outcomes in premature infants.
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Affiliation(s)
- Yangyang Qin
- Nursing Department, The First Affiliated Hospital of Henan University of Chinese Medicine, No. 19 Renmin Road, Jinshui District, Zhengzhou, 450099, He Nan, China
| | - Shu Liu
- Nursing Department, The First Affiliated Hospital of Henan University of Chinese Medicine, No. 19 Renmin Road, Jinshui District, Zhengzhou, 450099, He Nan, China.
| | - Yanming Yang
- Nursing Department, The First Affiliated Hospital of Henan University of Chinese Medicine, No. 19 Renmin Road, Jinshui District, Zhengzhou, 450099, He Nan, China
| | - Yuan Zhong
- Nursing Department, The First Affiliated Hospital of Henan University of Chinese Medicine, No. 19 Renmin Road, Jinshui District, Zhengzhou, 450099, He Nan, China
| | - Danshi Hao
- Henan University of Chinese Medicine, No. 156 Jinshui East Road, Jinshui District, Zhengzhou, China
| | - Han Han
- Obstetrics and Gynecology Department, The First Affiliated Hospital of Henan University of Chinese Medicine, No. 19 Renmin Road, Jinshui District, Zhengzhou, 450099, He Nan, China
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Séassau A, Munos P, Gire C, Tosello B, Carchon I. Neonatal Care Unit Interventions on Preterm Development. CHILDREN (BASEL, SWITZERLAND) 2023; 10:999. [PMID: 37371231 DOI: 10.3390/children10060999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 05/24/2023] [Accepted: 05/26/2023] [Indexed: 06/29/2023]
Abstract
Prematurity is becoming a real public health issue as more and more children are being born prematurely, alongside a higher prevalence of neurodevelopmental disorders. Early intervention programs in Neonatal Intensive Care Units (NICUs) correspond to these uni- or multi-sensorial solicitations aiming to prevent and detect complications in order to support the development of preterm infants. This article aims to distinguish sensory intervention programs according to the gradient of the type of solicitations, uni- or multi-modal, and according to the function of the person who performs these interventions. Uni-sensorial interventions are essentially based on proprioceptive, gustatory, or odorant solicitations. They allow, in particular, a reduction of apneas that support the vegetative states of the preterm infant. On the other hand, the benefits of multi-sensory interventions seem to have a longer-term impact. Most of them allow the support of the transition from passive to active feeding, an increase in weight, and the improvement of sleep-wake cycles. These solicitations are often practiced by caregivers, but the intervention of parents appears optimal since they are the main co-regulators of their preterm child's needs. Thus, it is necessary to co-construct and train the parents in this neonatal care.
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Affiliation(s)
- Alexia Séassau
- Centre Hospitalier du Pays d'Aix, 13100 Aix-en-Provence, France
| | | | - Catherine Gire
- Department of Neonatology, Hôpital Nord de Marseille, 13015 Marseille, France
| | - Barthélémy Tosello
- Department of Neonatology, Hôpital Nord de Marseille, 13015 Marseille, France
| | - Isabelle Carchon
- CHART Human and Artificial Cognition Laboratory at Ephe, École Pratique des Hautes Études-PSL Paris-Sciences-Lettres, 93322 Aubervilliers, France
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[Evidence-based guideline for neonatal pain management in China (2023)]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2023; 25:109-127. [PMID: 36854686 PMCID: PMC9979385 DOI: 10.7499/j.issn.1008-8830.2210052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/06/2022] [Indexed: 03/02/2023]
Abstract
Pain disrupts neonatal vital signs and internal environment homeostasis and affects the recovery process, and recurrent pain stimulation is one of the important risk factors for neurodevelopmental disorders and some chronic diseases. In order to standardize pain management practice in neonatal wards in China and effectively prevent and reduce the adverse effects of pain on the physical and mental development of neonates, National Clinical Research Center for Child Health and Diseases (Children's Hospital of Chongqing Medical University) convened a multidisciplinary panel to formulate the evidence-based guideline for neonatal pain management in China (2023 edition) following the principles and methods for the guideline development issued by the World Health Organization. Based on the best evidence and expert consensus, this guideline gives 26 recommendations for nine clinical issues, i.e., the classification and definition of neonatal pain, common sources of pain, pain assessment principles, pain assessment methods, analgesic principle, non-pharmaceutical analgesic methods, pharmaceutical analgesic methods, parental participation in pain management, and recording methods for pain management, so as to provide medical staff with guidance and a decision-making basis for neonatal pain assessment and analgesia management.
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Les expériences gustatives précoces persistent-elles à influencer les préférences alimentaires des enfants à l’âge scolaire ? NUTR CLIN METAB 2022. [DOI: 10.1016/j.nupar.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Nunes CRDN, Freitas NFD, Arruda JRP, Bartholomeu MDD, Valadares GC, Rodrigues TM, Azevedo VMGDO, Bouzada MCF. Association between early onset of skin-to-skin contact and mother-infant interaction at hospital discharge and six months of corrected age among preterm infants. Early Hum Dev 2022; 165:105525. [PMID: 34996020 DOI: 10.1016/j.earlhumdev.2021.105525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 12/10/2021] [Accepted: 12/14/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare mother-infant interaction between hospital discharge and at six months of corrected age of infants born ≤32 weeks and investigate the association between the onset of skin-to-skin contact and the difference in mother-infant interaction between discharge and six months of corrected age (CA) among preterm infants. MATERIAL AND METHODS Prospective observational study, in which 72 mother-infant dyads were evaluated. Preterm newborns (born with gestational age ≤ 32 weeks of gestational age) from two public maternity hospitals were assessed by means of video macro analysis of the mother-infant interaction according to the parameters adopted by the Mother-Baby Observation Protocol 0-6 (POIMB), at hospital discharge and at six months of corrected gestational age. Such variables as socioeconomic conditions, depression and maternal anxiety were controlled. Multivariate model was built. RESULTS Onset skin-to-skin contact within three days of life increased by 1.30 points for the best interactive infant behavior at discharge for the six months of CA. In addition, in relation to the tuning of the mother-infant dyad, the initiation of skin-to-skin contact at 20 days of life reduced 1.0 point significantly. Multiparous mothers or those exposed to cigarette smoke performed worse in the development of the dyad. CONCLUSION The preterm newborn should initiate skin-to-skin contact early and, whenever possible, by the third day of life to favor mother-infant interaction.
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Affiliation(s)
| | - Nathalia Faria de Freitas
- Universidade Federal de Minas Gerais, 190 Professor Alfredo Balena Ave. Santa Efigênia, Belo Horizonte, MG, 30130-100, Brazil
| | | | | | - Gislene Cristina Valadares
- Universidade Federal de Minas Gerais, 190 Professor Alfredo Balena Ave. Santa Efigênia, Belo Horizonte, MG, 30130-100, Brazil
| | - Thalyta Magalhães Rodrigues
- Universidade Federal de Minas Gerais, 190 Professor Alfredo Balena Ave. Santa Efigênia, Belo Horizonte, MG, 30130-100, Brazil
| | | | - Maria Cândida Ferrarez Bouzada
- Universidade Federal de Minas Gerais, 190 Professor Alfredo Balena Ave. Santa Efigênia, Belo Horizonte, MG, 30130-100, Brazil
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Duchamp-Viret P, Nguyen HK, Maucort-Boulch D, Remontet L, Guyon A, Franco P, Cividjian A, Thevenet M, Iwaz J, Galletti S, Kassai B, Cornaton E, Plaisant F, Claris O, Gauthier-Moulinier H. Protocol of controlled odorant stimulation for reducing apnoeic episodes in premature newborns: a randomised open-label Latin-square study with independent evaluation of the main endpoint (PREMODEUR). BMJ Open 2021; 11:e047141. [PMID: 34518252 PMCID: PMC8438960 DOI: 10.1136/bmjopen-2020-047141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Apnoea affects 85% of premature infants under 34 weeks of age and would be an important risk factor for subsequent neuropsychological disorders. Currently, premature children with life-threatening apnoeas receive stimulants such as methylxanthines (mainly, caffeine) or doxapram (an analeptic unlicensed in children under 15). However, these products have undesirable effects (hyperarousal, irritability, sleep disorders, tachycardia) and are not always effective because apnoea does persist in some premature newborns. Previous studies have indicated that odorant stimulation, a non-invasive intervention, may stimulate the respiratory rhythm. The objective of the present protocol is to reduce the occurrence of apnoeic episodes in premature newborns by controlled odorant stimulation added to current pharmacological treatments. METHODS AND ANALYSIS The project is a randomised open-label Latin-square trial with independent evaluation of the main endpoint. It will include 60 preterm neonates from two university hospital neonatal intensive care units over 2 years (2021-2023). Each newborn will receive no (S0), sham (S1) or real olfactory stimulation (S2) in random order. During S2, three distinct odorants (mint, grapefruit and vanilla) will be delivered successively, in puffs, over 24 hours. Mint and grapefruit odours stimulate the main and the trigeminal olfactory pathways, whereas vanilla odour stimulates only the main olfactory pathway. A statistical analysis will compare the incidence of apnoeic episodes during S1 versus S2 using a mixed effects Poisson model. ETHICS AND DISSEMINATION Ethical approval was obtained from the Comité de Protection des Personnes Île-de-France XI (# 2017-AO13-50-53). The results will be disseminated through various scientific meetings, specialised peer-reviewed journals and, whenever possible, posted on appropriate public websites. TRIAL REGISTRATION NUMBER NCT02851979; Pre-results.
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Affiliation(s)
- Patricia Duchamp-Viret
- Centre de Recherche en Neurosciences de Lyon, Bron, France
- Équipe de Neuro-Éthologie Sensorielle, UMR 5292, Bron/Saint-Étienne, Rhône-Alpes, France
| | - Huu Kim Nguyen
- Service de néonatologie et de réanimation néonatale, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France
- Département de Pharmacotoxicologie, Hospices Civils de Lyon, Lyon, France
| | - Delphine Maucort-Boulch
- Service de Biostatistique-Bioinformatique, Hospices Civils de Lyon, Pôle Santé Publique, Lyon, France
- Université de Lyon, Lyon, France
| | - Laurent Remontet
- Service de Biostatistique-Bioinformatique, Hospices Civils de Lyon, Pôle Santé Publique, Lyon, France
- Équipe Biostatistique-Santé, CNRS UMR 5558, Laboratoire de Biométrie et Biologie Évolutive, Villeurbanne, France
| | - Aurore Guyon
- Unité de sommeil pédiatrique, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France
| | - Patricia Franco
- Unité de sommeil pédiatrique, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France
| | - Andrei Cividjian
- Département de Cardiologie, Hospices Civils de Lyon, Hôpital de la Croix-Rousse, Lyon, France
- Alpha-2 Ltd, Lyon, France
| | - Marc Thevenet
- Centre de Recherche en Neurosciences de Lyon, Bron, France
- Équipe de Neuro-Éthologie Sensorielle, UMR 5292, Bron/Saint-Étienne, Rhône-Alpes, France
| | - Jean Iwaz
- Service de Biostatistique-Bioinformatique, Hospices Civils de Lyon, Pôle Santé Publique, Lyon, France
- Équipe Biostatistique-Santé, CNRS UMR 5558, Laboratoire de Biométrie et Biologie Évolutive, Villeurbanne, France
| | - Sonia Galletti
- Équipe Biostatistique-Santé, CNRS UMR 5558, Laboratoire de Biométrie et Biologie Évolutive, Villeurbanne, France
- Centre d'investigation clinique, Lyon, France
| | - Behrouz Kassai
- Équipe Biostatistique-Santé, CNRS UMR 5558, Laboratoire de Biométrie et Biologie Évolutive, Villeurbanne, France
- Centre d'investigation clinique, Lyon, France
| | - Elise Cornaton
- Service de néonatologie et de réanimation néonatale, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France
| | - Franck Plaisant
- Service de néonatologie et de réanimation néonatale, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France
| | - Olivier Claris
- Service de néonatologie et de réanimation néonatale, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France
| | - Hélène Gauthier-Moulinier
- Service de néonatologie et de réanimation néonatale, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France
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Frie J, Bartocci M, Kuhn P. Neonatal cortical perceptions of maternal breast odours: A fNIRS study. Acta Paediatr 2020; 109:1330-1337. [PMID: 31782829 DOI: 10.1111/apa.15114] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 11/09/2019] [Accepted: 11/26/2019] [Indexed: 11/28/2022]
Abstract
AIM The aim was to determine whether preterm and full-term newborn infants could process maternal breast odour at a cortical level. METHODS Newborn infants were exposed to cloths containing their own mother's breast odour and freshly laundered control cloths for 10 seconds, while functional near-infrared spectroscopy measured cortical activation in their olfactory processing areas. We studied 45 newborn infants born at 28-41 weeks of gestation and divided them into three groups: full-term (37-41 weeks), late preterm (33-36 weeks) and very preterm (28-32 weeks). Cortical activation was defined as a regional increase of oxyhaemoglobin following maternal breast odour stimuli. RESULTS Full-term infants demonstrated bilateral activation of their olfactory cortices following exposure to maternal breast odour. Late preterm infants and very preterm boys exhibited unilateral cortical activation, unlike very preterm girls. CONCLUSION Infants born from 32 weeks, and possibly earlier, could process low concentration maternal odours at a cortical level, which suggests they were more aware of their environment. These findings could make a significant contribution to improving the sensory environment of preterm infants and improve bonding.
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Affiliation(s)
- Jakob Frie
- Neonatal Research Unit Department of Women's and Children's Health Karolinska Institute Stockholm Sweden
- Department of Neonatal Medicine Astrid Lindgren Children's Hospital Karolinska University Hospital Stockholm Sweden
| | - Marco Bartocci
- Neonatal Research Unit Department of Women's and Children's Health Karolinska Institute Stockholm Sweden
- Department of Neonatal Medicine Astrid Lindgren Children's Hospital Karolinska University Hospital Stockholm Sweden
| | - Pierre Kuhn
- Neonatal Research Unit Department of Women's and Children's Health Karolinska Institute Stockholm Sweden
- Service de Médecine et Réanimation du Nouveau‐né Hôpital de Hautepierre Centre Hospitalier Universitaire de Strasbourg Strasbourg France
- Institut des Neurosciences Cellulaires et Intégratives Centre National de la Recherche Scientifique et Unistra Strasbourg France
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Systematic review and meta-analysis of olfactive stimulation interventions to manage procedural pain in preterm and full-term neonates. Int J Nurs Stud 2020; 110:103697. [PMID: 32738721 DOI: 10.1016/j.ijnurstu.2020.103697] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 06/13/2020] [Accepted: 06/15/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND Preterm and full-term neonates undergo many painful procedures during their hospitalization in the neonatal intensive care unit. Unrelieved and repeated pain can have important repercussions on their motor and intellectual development. Still, pain management interventions are limited for neonates. OBJECTIVE This systematic review aimed to evaluate the effectiveness of olfactive stimulation interventions on the pain response of preterm and full-term infants during painful procedures. DESIGN Systematic review and meta-analysis. DATA SOURCES An electronic search was conducted from inception to August 2019 in PubMed, MEDLINE, Embase, CINAHL, PsycINFO, Web of Sciences, CENTRAL, Scopus and ProQuest. REVIEW METHODS Study selection, data extraction, assessment of risk of bias and quality of evidence were performed by two independent reviewers. RESULTS 3311 studies were screened. Of the 14 studies included studies (n = 1028 infants), results from 10 were combined in meta-analysis. The latter demonstrated that olfactive stimulation interventions using a familiar odor were effective compared to standard care on pain reactivity (SMD -0.69; 95% CI -0.93 to -0.44; I2 = 20%, p < 0.00001), pain regulation (SMD -0.40; 95% CI -0.66 to -0.14; I2 = 13%, p = 0.002), crying duration during (SMD -0.42; 95% CI -0.73 to -0.10; I2 = 47%, p = 0.009) and after the procedure (SMD -0.37; 95% CI -0.68 to -0.07; I2 = 0%, p = 0.01), heart rate after the procedure (MD -3.87; 95% CI -7.36 to -0.38; I2 = 99%, p = 0.03), oxygen saturation during (MD -0.47; 95% CI -0.86 to -0.08; I2 = 91%, p = 0.02) and after the procedure (MD -0.56; 95% CI -0.99 to -0.13; I2 = 99%, p = 0.01). No adverse event was reported. CONCLUSION These findings are based on low to very low quality of evidence limiting our confidence in effect estimates. More rigorous trials with a larger sample size are needed to enhance the comprehension of the mechanisms underlying olfactive stimulation interventions and the interventions' efficacy.
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Davidson J, Ruthazer R, Maron JL. Optimal Timing to Utilize Olfactory Stimulation with Maternal Breast Milk to Improve Oral Feeding Skills in the Premature Newborn. Breastfeed Med 2019; 14:230-235. [PMID: 30882237 PMCID: PMC10027347 DOI: 10.1089/bfm.2018.0180] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background: Olfactory maturation is essential for successful oral feeding. Previous studies have suggested that olfactory stimulation with maternal breast milk may expedite oral feeding skills in the premature infant; however, the optimal developmental window to utilize this intervention and sex-specific responses to stimuli are largely unknown. Objectives: To determine individual responses to olfactory stimulation with mother's own milk (MOM) on feeding outcomes in premature newborns. Materials and Methods: Infants born between 28 0/7 and 33 6/7 weeks' gestation (n = 36) were randomized to receive either MOM or water (sham) stimulus during the learning process of oral feeding. Clinical and feeding outcomes were recorded. Statistical analyses examined the effect of stimulation with MOM on feeding outcomes stratified for age and sex. Results: Overall, there was no significant difference between sham infants compared with MOM infants in mean postmenstrual age of full oral feeds (sham: 35 5/7 versus MOM 36 0/7; p = 0.37). However, when stratified by gestational age (GA), infants born <31 weeks' gestation who received MOM stimulation learned to feed sooner than controls (p = 0.06), whereas infants born ≥31 weeks' gestation learned to feed later than controls (p = 0.20) with a significant interaction (p = 0.02) between the stimulus (MOM versus sham) and dichotomized GA (<31 versus ≥31 weeks). There were no sex differences in response to olfactory stimulus. Conclusions: Infants born <31 weeks' GA who received MOM stimulation learned to feed sooner than control infants and the impact of MOM is significantly different between infants born before or after 31 weeks GA. These data suggest there may be an optimal time in development to utilize maternal breast milk to expedite oral feeding maturation in the premature newborn.
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Affiliation(s)
- Jessica Davidson
- 1 Division of Newborn Medicine, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Robin Ruthazer
- 2 Institute for Clinical Research and Health Policy Studies, Biostatistics, Epidemiology, and Research Design Center, Tufts Medical Center, Boston, Massachusetts
- 3 Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
| | - Jill L Maron
- 1 Division of Newborn Medicine, Department of Pediatrics, University of Utah, Salt Lake City, Utah
- 4 Mother Infant Research Institute, Tufts Medical Center, Boston, Massachusetts
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Abstract
This chapter focuses on the development of the human olfactory system. In this system, function does not require full neuroanatomical maturity. Thus, discrimination of odorous molecules, including a number within the mother's diet, occurs in amniotic fluid after 28-30 weeks of gestation, at which time the olfactory bulbs are identifiable by MRI. Hypoplasia/aplasia of the bulbs is documented in the third trimester and postnatally. Interestingly, olfactory axons project from the nasal epithelium to the telencephalon before formation of the olfactory bulbs and lack a peripheral ganglion, but the synaptic glomeruli of the future olfactory bulb serves this function. Histologic lamination of the olfactory bulb is present by 14 weeks, but maturation remains incomplete at term for neuronal differentiation, synaptogenesis, myelination, and persistence of the normal transitory fetal ventricular recess. Myelination occurs postnatally. Although olfaction is the only sensory system without direct thalamic projections, the olfactory bulb and anterior olfactory nucleus are, in effect, thalamic surrogates. For example, many dendro-dendritic synapses occur within the bulb between GABAergic granular neurons and periglomerular neurons. Moreover, bulbar synaptic glomeruli are analogous to peripheral ganglia of other sensory cranial nerves. The olfactory tract contains much gray as well as white matter. The olfactory epithelium and bulb both incorporate progenitor cells at all ages. Diverse malformations of the olfactory bulb can be detected by clinical examination, imaging, and neuropathology; indeed, olfactory reflexes of the neonate can be reliably tested. We recommend that such testing be routine in the neonatal neurologic examination, especially in children with brain malformations, endocrinopathies, chromosomopathies, genetic/metabolic disorders, and perinatal hypoxic/ischemic encephalopathy.
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Affiliation(s)
- Harvey B Sarnat
- Department of Paediatrics, University of Calgary Cumming School of Medicine and Alberta Children's Hospital Research Institute, Calgary, AB, Canada; Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine and Alberta Children's Hospital Research Institute, Calgary, AB, Canada; Department of Pathology and Laboratory Medicine (Neuropathology), University of Calgary Cumming School of Medicine and Alberta Children's Hospital Research Institute, Calgary, AB, Canada.
| | - Laura Flores-Sarnat
- Department of Paediatrics, University of Calgary Cumming School of Medicine and Alberta Children's Hospital Research Institute, Calgary, AB, Canada; Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine and Alberta Children's Hospital Research Institute, Calgary, AB, Canada
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Cao Van H, Guinand N, Damis E, Mansbach AL, Poncet A, Hummel T, Landis BN. Olfactory stimulation may promote oral feeding in immature newborn: a randomized controlled trial. Eur Arch Otorhinolaryngol 2017; 275:125-129. [PMID: 29119319 DOI: 10.1007/s00405-017-4796-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 10/31/2017] [Indexed: 10/18/2022]
Abstract
Premature newborns have an increased mortality and morbidity due to respiratory immaturity and inefficient oral feeding performance. Transient assistance with feeding tubes until oral performance improves is required with consequent hospital admission. Based on a controlled and randomized study, we tested whether olfactory stimulation compared to odorless stimulation could accelerate the switch from feeding tube to satisfactory oral feeding. Fifty newborns were included and randomly assigned to either odorless or olfactory stimulation with anise or cinnamon. The main outcome measurement was the duration of the hospital stay. The odor-stimulated group could be discharged from hospital on average 3.4 days earlier than the control group (p = 0.12). When including only more mature newborns into the analysis (n = 39), the difference was statistically significant (p < 0.05). This trend emphasizes that olfaction may have its place in early feeding stimulation.
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Affiliation(s)
- H Cao Van
- ENT Department, University Children's Hospital R. Fabiola, Brussels, Belgium.,Pediatric Otolaryngology Unit, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - N Guinand
- Rhinology-Olfactolgy Unit, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland
| | - E Damis
- Department of Neonatology, University Hospital Brugmann, Free University of Brussels (ULB), Brussels, Belgium
| | - A L Mansbach
- ENT Department, University Children's Hospital R. Fabiola, Brussels, Belgium
| | - A Poncet
- Statistical Unit, Epidemiology Department, University Hospitals of Geneva, Geneva, Switzerland
| | - T Hummel
- Smell and Taste Clinic, Department of Otorhinolaryngology, Technische Universität Dresden, Dresden, Germany
| | - B N Landis
- Rhinology-Olfactolgy Unit, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland.
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De Clifford-Faugère G, Lavallée A, Aita M. Olfactive stimulation interventions for managing procedural pain in preterm and full-term neonates: a systematic review protocol. Syst Rev 2017; 6:203. [PMID: 29041964 PMCID: PMC5646110 DOI: 10.1186/s13643-017-0589-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 09/28/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While hospitalized in the NICU, preterm neonates undergo many painful procedures. This may be the same for full-term neonates when longer hospitalization is required. Untreated and repeated pain has short-term as well as long-term consequences for these neonates. Pharmacological pain management methods have many limitations in their applications for both preterm and full-term neonates. A combination of different non-pharmacological methods is recommended for pain management. The effect of olfactive stimulation as a non-pharmacological pain management method was investigated by a few studies in the past years with premature and term neonates, but no systematic review has been conducted. The objective of this systematic review is to evaluate the effect of olfactive stimulation intervention on the pain response of preterm and full-term neonates during painful procedures. METHODS An electronic search will be conducted in various databases such as PubMed (1946 to date), MEDLINE (1946 to date), CINAHL (1981 to date), Embase (1947 to date), PsycINFO (1806 to date), Web of Science (1945 to date), CENTRAL and Scopus (1960 to date), and Proquest, without restriction for the year of publication. Only studies published in English or French will be included. The search will be conducted using the following three concepts: pain, odors, and neonates. Selection of articles, data extraction, and assessment of risk of bias will be conducted by two independent researchers. A third researcher will intervene in case of disagreement. According to the availability of studies and data homogeneity, the results will be combined to perform a meta-analysis, or they will be described by a narrative synthesis. DISCUSSION This systematic review will provide light on the current state of knowledge on the effectiveness of olfactive stimulation interventions for managing pain in preterm and full-term neonates. This review will guide clinical practice as well as research to improve preterm and full-term neonates' pain management and prevent short-term and long-term complications caused by pain. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017058021.
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Affiliation(s)
- Gwenaëlle De Clifford-Faugère
- Faculty of Nursing, Université de Montréal, C.P. 6128 Succ. Centre-ville, Montreal, H3C 3J7, Canada. .,CHU Sainte-Justine Research Center, Montreal, Canada.
| | - Andréane Lavallée
- Faculty of Nursing, Université de Montréal, C.P. 6128 Succ. Centre-ville, Montreal, H3C 3J7, Canada.,CHU Sainte-Justine Research Center, Montreal, Canada
| | - Marilyn Aita
- Faculty of Nursing, Université de Montréal, C.P. 6128 Succ. Centre-ville, Montreal, H3C 3J7, Canada.,CHU Sainte-Justine Research Center, Montreal, Canada.,Quebec Network of Nursing Intervention Research (RRISIQ), Montreal, Canada
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14
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Frie J, Bartocci M, Lagercrantz H, Kuhn P. Cortical Responses to Alien Odors in Newborns: An fNIRS Study. Cereb Cortex 2017; 28:3229-3240. [DOI: 10.1093/cercor/bhx194] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Accepted: 07/13/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jakob Frie
- Neonatal Research Unit, Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Department of Neonatal Medicine, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Marco Bartocci
- Neonatal Research Unit, Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Department of Neonatal Medicine, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Hugo Lagercrantz
- Neonatal Research Unit, Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
| | - Pierre Kuhn
- Neonatal Research Unit, Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Service de Médecine et Réanimation du Nouveau-né, Hôpital de Hautepierre, Centre Hospitalier Universitaire de Strasbourg, France
- Institut de Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique et Unistra, Strasbourg, France
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15
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Sarnat HB, Flores-Sarnat L, Wei XC. Olfactory Development, Part 1: Function, From Fetal Perception to Adult Wine-Tasting. J Child Neurol 2017; 32:566-578. [PMID: 28424010 DOI: 10.1177/0883073817690867] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Discrimination of odorous molecules in amniotic fluid occur after 30 weeks' gestation; fetuses exhibit differential responses to maternal diet. Olfactory reflexes enable reliable neonatal testing. Olfactory bulbs can be demonstrated reliably by MRI after 30 weeks' gestation, and their hypoplasia or aplasia also documented by late prenatal and postnatal MRI. Olfactory axons project from nasal epithelium to telencephalon before olfactory bulbs form. Fetal olfactory maturation remains incomplete at term for neuronal differentiation, synaptogenesis, myelination, and persistence of the transitory fetal ventricular recess. Immaturity does not signify nonfunction. Olfaction is the only sensory system without thalamic projection because of its own intrinsic thalamic equivalent. Diverse malformations of the olfactory bulb can be diagnosed by clinical examination, imaging, and neuropathology. Some epileptic auras might be primarily generated in the olfactory bulb. Cranial nerve 1 should be tested in all neonates and especially in patients with brain malformations, endocrinopathies, chromosomopathies, and genetic/metabolic diseases.
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Affiliation(s)
- Harvey B Sarnat
- 1 Department of Paediatrics, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,2 Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,3 Department of Pathology and Laboratory Medicine (Neuropathology), University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,5 Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
| | - Laura Flores-Sarnat
- 1 Department of Paediatrics, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,2 Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,3 Department of Pathology and Laboratory Medicine (Neuropathology), University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,5 Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
| | - Xing-Chang Wei
- 4 Department of Radiology and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,5 Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
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16
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Beker F, Opie G, Noble E, Jiang Y, Bloomfield FH. Smell and Taste to Improve Nutrition in Very Preterm Infants: A Randomized Controlled Pilot Trial. Neonatology 2017; 111:260-266. [PMID: 27902988 DOI: 10.1159/000450883] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 09/19/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND The perception of smell and taste, though present early in development, is not routinely considered in the care of preterm infants. Smell and taste are known to increase gut motility, insulin secretion, and the release of appetite, digestive and metabolic hormones. OBJECTIVE We aimed to investigate the effect of regular smell and taste on the time from birth to full enteral feeds, and the feasibility of the study protocol in very preterm infants. METHODS In a randomized controlled trial, infants <29 weeks' postmenstrual age (PA) were assigned to receive either the smell and taste of milk before each feed or to have no exposure to the smell and taste of milk (control). RESULTS Infants in the treatment group (n = 28) and control group (n = 23) were born at a mean (SD) PA of 26.7 (1.5) and 27.2 (1.4) weeks, respectively. They reached full enteral feeds at a median (IQR) of 13.5 (10.0-19.0) and 15.5 (11.0-22.0) days, respectively. Survival analysis showed an adjusted hazard ratio of 1.63 (95% confidence interval 0.91-2.91; p = 0.10) for the effect on the time to establish full enteral feeds. Repeated-measures analysis indicated significant group differences in weight z scores at 36 weeks' PA and at discharge in favor of the intervention (p < 0.05). CONCLUSION These data indicate that the smell and taste of milk may improve milk tolerance and weight in preterm infants. The role of regular smell and taste in promoting enteral nutrition and growth in preterm infants merits a larger trial powered to detect important outcomes.
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Affiliation(s)
- Friederike Beker
- Neonatal Services, Mercy Hospital for Women, Melbourne, VIC, Australia
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17
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Dubedout S, Cascales T, Mas E, Bion A, Vignes M, Raynaud JP, Olives JP. Troubles du comportement alimentaire restrictifs du nourrisson et du jeune enfant : situations à risque et facteurs favorisants. Arch Pediatr 2016; 23:570-6. [DOI: 10.1016/j.arcped.2016.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 02/22/2016] [Accepted: 03/19/2016] [Indexed: 01/31/2023]
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18
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Sarnat HB, Yu W. Maturation and Dysgenesis of the Human Olfactory Bulb. Brain Pathol 2016; 26:301-18. [PMID: 26096058 PMCID: PMC8028954 DOI: 10.1111/bpa.12275] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 06/09/2015] [Indexed: 12/22/2022] Open
Abstract
The olfactory bulb with its unique architecture was studied for neuronal maturation in human fetuses. Neuroblasts stream into the olfactory bulb from the rostral telencephalon and secondarily migrate radially. The transitory olfactory ventricular recess regresses postnatally. Olfactory is the only sensory system without thalamic projections but incorporates intrinsic thalamic equivalents. The bulb is a repository of progenitor cells. Maturation of the bulb and tract was studied in 18 normal human fetuses of 16-41 weeks gestation; mid-gestational twins with hydrocephalus; 7 arrhinencephaly/holoprosencephaly; 2 olfactory dysgeneses. Multiple immunoreactivities were performed. Synaptophysin around mitral neurons, in a few synaptic glomeruli and concentric lamination of the outer granular layer, was seen at 16 weeks. Outer granular neurons exhibited NeuN at 16 weeks, only 2/3 were reactive at term. Concentric alternating sheets of granular neurons and their dendrodendritic synapses are seen during maturation. Calretinin reactivity is seen in neurons and neurites, primary olfactory nerve axons, periglomerular cells and neuroepithelial cells surrounding the ventricular recess; reactivity occurs later in synaptic glomeruli than with synaptophysin; not all glomeruli are strongly reactive even at term. Nestin- and vimentin-reactive bipolar progenitor cells were demonstrated at all ages and extend into the olfactory tract. Myelin is demonstrated by Luxol fast blue (LFB) only postnatally. In hydrocephalus, the olfactory recess is dilated. Mitral cell dispersion, disrupted glomeruli, heterotopia and maturational delay are seen in some dysgeneses. Malformations exhibit unique findings. Fusion of hypoplastic bulbs can occur. Abnormal architecture is seen in hemimegalencephaly. More documentation of olfactory dysgenesis is needed in other major brain malformations.
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Affiliation(s)
- Harvey B. Sarnat
- Department of PaediatricsUniversity of Calgary Faculty of Medicine and Alberta Children's Hospital Research InstituteCalgaryABCanada
- Department of Pathology and Laboratory Medicine (Neuropathology)University of Calgary Faculty of Medicine and Alberta Children's Hospital Research InstituteCalgaryABCanada
- Department of Clinical NeurosciencesUniversity of Calgary Faculty of Medicine and Alberta Children's Hospital Research InstituteCalgaryABCanada
| | - Weiming Yu
- Department of PaediatricsUniversity of Calgary Faculty of Medicine and Alberta Children's Hospital Research InstituteCalgaryABCanada
- Department of Pathology and Laboratory Medicine (Paediatric Pathology)University of Calgary Faculty of Medicine and Alberta Children's Hospital Research InstituteCalgaryABCanada
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Kuhn P, Zores C, Astruc D, Dufour A, Casper C. [Sensory system development and the physical environment of infants born very preterm]. Arch Pediatr 2011; 18 Suppl 2:S92-102. [PMID: 21763981 DOI: 10.1016/s0929-693x(11)71097-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The sensory systems develop in several sequences, with a process specific to each system and with a transnatal continuum. This development is based partly on interactions between the fetus and the newborn and their physical and human environments. These interactions are key drivers of the child development. The adaptation of the newborn's environment is crucial for his survival, his well-being and his development, especially if he is born prematurely. The physical environment of the hospital where immature infants are immersed differs greatly from the uterine environment from which they were extracted prematurely. There are discrepancies between their sensory expectations originating in the antenatal period and the atypical stimuli that newborns encounter in their postnatal nosocomial environment. These assertions are valid for all sensory modalities. Many studies have proven that very preterm infants are highly sensitive to this environment which can affect their physiological and behavioural well being. Moreover, it can alter their perception of important human sensory signals, particularly the ones coming from their mother. The long term impacts of this environment are more difficult to identify due to the multi-sensory nature of these stimuli and the multifactorial origin of the neurological disorders that these children may develop. However, the adaptation of their physical environment is one of the corner stones of specific developmental care programs, like the NIDCAP program that has been shown to be successful to improve their short and medium term outcomes. The architectural design, technical equipment and used health-care products, and the strategies and organizations of care are the main determinants of the physical environment of these children. Recommendations for the hospital environment, integrating a newborn's developmental perspective, have been made available. They should be applied more widely and should be completed. Technological equipment advances are also expected to allow better compliance to them. All these evolutions are completely in accordance with the concept of humane neonatal care.
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Affiliation(s)
- P Kuhn
- Service de Médecine et Réanimation Néonatale, Hôpital de Hautepierre, CHU Strasbourg, 28 Avenue Molière 67098 Strasbourg cedex, France.
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Kuhn P, Astruc D, Messer J, Marlier L. Exploring the olfactory environment of premature newborns: a French survey of health care and cleaning products used in neonatal units. Acta Paediatr 2011; 100:334-9. [PMID: 21054514 DOI: 10.1111/j.1651-2227.2010.02076.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM To assess the main determinants of the newborn's nosocomial olfactory environment. METHODS An electronic questionnaire was sent to 99 neonatal units in France. Senior nurses and/or physicians described the nature and use of skin care products (e.g. umbilical cord and skin disinfectants, adhesive removers), lubrications used for tubes positioning, disinfectants used to clean materials, hand hygiene products (e.g. alcohol-based hand rubs, soaps) and newborns' bath. RESULTS Nine groups of products and 76 distinct commercial preparations were identified. Depending on their level of respiratory support, preterm newborns were estimated to be exposed to nosocomial odours (NO) an average of 1320-1800 times during their first month of life. During their whole hospital stay, newborns of 28 and 32 weeks of gestational age could be exposed to NOs products an average of 3448 and 2024 times, respectively. The use of these products varied among medical centres. Newborns were most frequently exposed to the odour of aqueous alcoholic solutions. CONCLUSIONS Vulnerable preterm infants are daily exposed to multiple NOs most of them be considered as irritant for the nose. Minimizing infants' exposure to them would be beneficial. Future studies should describe the exact olfactory properties of the products considered essential for infant care and should assess their effects on the infant's well-being and development.
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Affiliation(s)
- Pierre Kuhn
- Service de Pédiatrie 2, Pôle Médico-chirurgical pédiatrique, Hôpital de Hautepierre, Centre Hospitalier Universitaire de Strasbourg, Strasbourg, France.
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22
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Marlier L. Émergence et développement précoce des préférences olfactives et alimentaires. Arch Pediatr 2009; 16:532-4. [DOI: 10.1016/s0929-693x(09)74056-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
OBJECTIVE To test if enhancing maternal skin-to-skin contact, or kangaroo mother care (KMC) by adding rocking, singing and sucking is more efficacious than simple KMC for procedural pain in preterm neonates. STUDY DESIGN Preterm neonates (n=90) between 32 0/7 and 36 0/7 weeks' gestational age participated in a single-blind randomized crossover design. The infant was held in KMC with the addition of rocking, singing and sucking or the infant was held in KMC without additional stimulation. The Premature Infant Pain Profile was the primary outcome with time to recover as the secondary outcome. A repeated-measures analysis of covariance was employed for analyses. RESULT There were no significant differences in any of the 30 s time periods over the 2 min of blood sampling nor in time to return to baseline. Compared to historical controls of the same age in incubator, the pain scores were lower and comparable to other studies of KMC. There were site differences related to lower scores with the use of sucrose in one site and higher scores in younger, sicker infants in another site. CONCLUSION The sensorial stimulations from skin-to-skin contact that include tactile, olfactory sensations from the mother are sufficient to decrease pain response in premature neonates. Other studies showing that rocking, sucking and music were efficacious were independent of skin-to-skin contact, which, when used alone has been shown to be effective as reported across studies.
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Gaugler C, Marlier L, Messer J. [Sensory stimulations for the treatment of idiopathic apneas of prematurity]. Arch Pediatr 2007; 14:485-9. [PMID: 17320360 DOI: 10.1016/j.arcped.2007.01.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2006] [Accepted: 01/16/2007] [Indexed: 11/22/2022]
Abstract
Idiopathic apneas of prematurity remain an alarming problem in neonatology. Long-term effects on neurological development cannot be excluded. Two principal treatments are currently applied to prevent apneic attacks: analeptics (methylxanthines and doxapram) and continuous positive airway pressure. Several studies suggest the use of sensory stimulations for curative or preventive treatments. Protocols of tactile, kinesthetic and auditory stimulations are described and their respective efficacy is discussed. We also resume a recent preliminary study which suggested the use of an olfactory stimulation as preventive treatment. A beneficial effect, specifically on apnea associated with severe bradycardia, was observed. Complementary studies are necessary to confirm the benefit of such sensory stimulations for apneas of prematurity, and, if so, to allow clinical applications.
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Affiliation(s)
- C Gaugler
- Service de Pédiatrie-2, Centre Hospitalier Régional Universitaire de Hautepierre, 1, avenue Molière, 67098 Strasbourg, France
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