A controlled trial of skin-to-skin contact in extremely preterm infants

Effectiveness and family experiences of interventions promoting partnerships between families and pediatric and neonatal intensive care units: a mixed methods systematic review

OBJECTIVE

The objective of this mixed methods review was to examine the effectiveness and family experiences of interventions promoting partnerships between families and the multidisciplinary health care team in pediatric and neonatal intensive care units.

INTRODUCTION

Hospitalization of infants and children in neonatal intensive care units and pediatric intensive care units has a significant effect on their families, including increased stress, anxiety, and depression. Available evidence syntheses focused on specific family-centered care, but not on partnership, which is another aspect that may improve the families' outcomes and experiences.

INCLUSION CRITERIA

This review focused on effectiveness and experiences of interventions by health professionals in partnership with families of infants or children hospitalized in an intensive care unit. The type of intervention was a partnership between the health care team and the family, and focused on outcomes of stress, anxiety, depression, quality of life, attachment, or satisfaction with family-centered care.

METHODS

The JBI methodology for convergent segregated mixed methods systematic reviews was followed using the standardized JBI critical appraisal and data extraction tools. Ten databases were searched from January 2000 to April 2022. Findings of quantitative studies were statistically pooled through meta-analyses and those that could not pooled were reported in a narrative format. Qualitative studies were pooled through meta-synthesis.

RESULTS

This review included 6 qualitative and 42 quantitative studies. There was mixed methodological quality and all studies were included regardless of methodological quality. Meta-analyses showed positive improvements in anxiety, satisfaction with family-centered care, and stress, yet no conclusive effects in attachment and depression. These results should be interpreted with caution due to high heterogeneity. Qualitative analysis resulted in 2 synthesized findings: "Interventions that incorporate partnerships between families and the health care team can improve the family's experience and capacity to care for the child" and "Having a child in intensive care can be an experience of significant impact for families" Integration of quantitative and qualitative evidence revealed some congruence between findings; however, the paucity of qualitative evidence minimized the depth of this integration.

CONCLUSIONS

Partnership interventions can have a positive impact on parents of children in intensive care units, with improvements seen in stress, anxiety, and satisfaction with family-centered care.

REVIEW REGISTRATION

PROSPERO CRD42019137834.

NICU sensory experiences associated with positive outcomes: an integrative review of evidence from 2015-2020

To inform changes to the Supporting and Enhancing NICU Sensory Experiences (SENSE) program, studies investigating sensory-based interventions in the NICU with preterm infants born ≤32 weeks were identified. Studies published between October 2015 to December 2020, and with outcomes related to infant development or parent well-being, were included in this integrative review. The systematic search used databases including MEDLINE, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, and Google Scholar. Fifty-seven articles (15 tactile, 9 auditory, 5 visual, 1 gustatory/olfactory, 5 kinesthetic, and 22 multimodal) were identified. The majority of the sensory interventions that were identified within the articles were reported in a previous integrative review (1995-2015) and already included in the SENSE program. New evidence has led to refinements of the SENSE program, notably the addition of position changes across postmenstrual age (PMA) and visual tracking starting at 34 weeks PMA.

Non-pharmacological management of infant and young child procedural pain

BACKGROUND

Despite evidence of the long-term implications of unrelieved pain during infancy, it is evident that infant pain is still under-managed and unmanaged. Inadequately managed pain in infancy, a period of exponential development, can have implications across the lifespan. Therefore, a comprehensive and systematic review of pain management strategies is integral to appropriate infant pain management. This is an update of a previously published review update in the Cochrane Database of Systematic Reviews (2015, Issue 12) of the same title.

OBJECTIVES

To assess the efficacy and adverse events of non-pharmacological interventions for infant and child (aged up to three years) acute pain, excluding kangaroo care, sucrose, breastfeeding/breast milk, and music.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE-Ovid platform, EMBASE-OVID platform, PsycINFO-OVID platform, CINAHL-EBSCO platform and trial registration websites (ClinicalTrials.gov; International Clinical Trials Registry Platform) (March 2015 to October 2020). An update search was completed in July 2022, but studies identified at this point were added to 'Awaiting classification' for a future update.  We also searched reference lists and contacted researchers via electronic list-serves.  We incorporated 76 new studies into the review.  SELECTION CRITERIA: Participants included infants from birth to three years in randomised controlled trials (RCTs) or cross-over RCTs that had a no-treatment control comparison. Studies were eligible for inclusion in the analysis if they compared a non-pharmacological pain management strategy to a no-treatment control group (15 different strategies). In addition, we also analysed studies when the unique effect of adding a non-pharmacological pain management strategy onto another pain management strategy could be assessed (i.e. additive effects on a sweet solution, non-nutritive sucking, or swaddling) (three strategies). The eligible control groups for these additive studies were sweet solution only, non-nutritive sucking only, or swaddling only, respectively. Finally, we qualitatively described six interventions that met the eligibility criteria for inclusion in the review, but not in the analysis.  DATA COLLECTION AND ANALYSIS: The outcomes assessed in the review were pain response (reactivity and regulation) and adverse events. The level of certainty in the evidence and risk of bias were based on the Cochrane risk of bias tool and the GRADE approach. We analysed the standardised mean difference (SMD) using the generic inverse variance method to determine effect sizes.  MAIN RESULTS: We included total of 138 studies (11,058 participants), which includes an additional 76 new studies for this update. Of these 138 studies, we analysed 115 (9048 participants) and described 23 (2010 participants) qualitatively. We described qualitatively studies that could not be meta-analysed due to being the only studies in their category or statistical reporting issues. We report the results of the 138 included studies here. An SMD effect size of 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect. The thresholds for the I2 interpretation were established as follows: not important (0% to 40%); moderate heterogeneity (30% to 60%); substantial heterogeneity (50% to 90%); considerable heterogeneity (75% to 100%). The most commonly studied acute procedures were heel sticks (63 studies) and needlestick procedures for the purposes of vaccines/vitamins (35 studies). We judged most studies to have high risk of bias (103 out of 138), with the most common methodological concerns relating to blinding of personnel and outcome assessors. Pain responses were examined during two separate pain phases: pain reactivity (within the first 30 seconds after the acutely painful stimulus) and immediate pain regulation (after the first 30 seconds following the acutely painful stimulus). We report below the strategies with the strongest evidence base for each age group. In preterm born neonates, non-nutritive sucking may reduce pain reactivity (SMD -0.57, 95% confidence interval (CI) -1.03 to -0.11, moderate effect; I2 = 93%, considerable heterogeneity) and improve immediate pain regulation (SMD -0.61, 95% CI -0.95 to -0.27, moderate effect; I2 = 81%, considerable heterogeneity), based on very low-certainty evidence. Facilitated tucking may also reduce pain reactivity (SMD -1.01, 95% CI -1.44 to -0.58, large effect; I2 = 93%, considerable heterogeneity) and improve immediate pain regulation (SMD -0.59, 95% CI -0.92 to -0.26, moderate effect; I2 = 87%, considerable heterogeneity); however, this is also based on very low-certainty evidence. While swaddling likely does not reduce pain reactivity in preterm neonates (SMD -0.60, 95% CI -1.23 to 0.04, no effect; I2 = 91%, considerable heterogeneity), it has been shown to possibly improve immediate pain regulation (SMD -1.21, 95% CI -2.05 to -0.38, large effect; I2 = 89%, considerable heterogeneity), based on very low-certainty evidence. In full-term born neonates, non-nutritive sucking may reduce pain reactivity (SMD -1.13, 95% CI -1.57 to -0.68, large effect; I2 = 82%, considerable heterogeneity) and improve immediate pain regulation (SMD -1.49, 95% CI -2.20 to -0.78, large effect; I2 = 92%, considerable heterogeneity), based on very low-certainty evidence.  In full-term born older infants, structured parent involvement was the intervention most studied. Results showed that this intervention has little to no effect in reducing pain reactivity (SMD -0.18, 95% CI -0.40 to 0.03, no effect; I2 = 46%, moderate heterogeneity) or improving immediate pain regulation (SMD -0.09, 95% CI -0.40 to 0.21, no effect; I2 = 74%, substantial heterogeneity), based on low- to moderate-certainty evidence. Of these five interventions most studied, only two studies observed adverse events, specifically vomiting (one preterm neonate) and desaturation (one full-term neonate hospitalised in the NICU) following the non-nutritive sucking intervention. The presence of considerable heterogeneity limited our confidence in the findings for certain analyses, as did the preponderance of evidence of very low to low certainty based on GRADE judgements.

AUTHORS' CONCLUSIONS

Overall, non-nutritive sucking, facilitated tucking, and swaddling may reduce pain behaviours in preterm born neonates. Non-nutritive sucking may also reduce pain behaviours in full-term neonates. No interventions based on a substantial body of evidence showed promise in reducing pain behaviours in older infants. Most analyses were based on very low- or low-certainty grades of evidence and none were based on high-certainty evidence. Therefore, the lack of confidence in the evidence would require further research before we could draw a definitive conclusion.

The effectiveness of kangaroo mother care in lowering postpartum depression in mothers of preterm and low birth weight babies: a systematic review and meta-analysis

Background

Kangaroo mother care (KMC) intervention involves skin-to-skin contact between mother and infant. Some studies have shown a decrease in postpartum depression (PPD) in mothers of preterm and low birth weight (LBW) infants. However, the literature is scattered and of variable quality.

Aims

To conduct a systematic review of available literature and provide a comprehensive picture of the effect of KMC on PPD among mothers of preterm and LBW infants.

Methods

The study was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Guidelines. After PROSPERO registration, a systematic search was conducted using PubMed, Cochrane Central Library, and Google Scholar from the inception of the databases till 14 June 2021. Of the 2944 studies assessed for titles and abstracts, nine studies with 2042 participants were included in the review. Included articles targeted mothers with LBW (<2500 g) or preterm infants (<37 weeks), used an authentic PPD tool, and had standard care or an incubator as the control group. Studies not published in English and in which mothers had a previous psychiatric illness were excluded. The risk of bias was assessed using the Cochrane Risk of Bias Tool for randomized control trials and the Newcastle-Ottawa Scale for observational studies. All the results were converted to standard mean deviation and pooled together using a random-effects model with a 95% CI. A P-value of less than 0.05 is considered significant.

Results

KMC Intervention was significantly associated with a lower depression score than control groups. The reduction in depression in the intervention (KMC) group was moderate: SMD=-0.38 (-0.68 to -0.08; 95% CI; I 2=86%; P=0.013). No significant difference was found between the PPD scores of both groups using the Edinburgh Postpartum Depression Scale score.

Conclusions

The authors conclude that the negative effects of LBW and preterm birth experience on maternal mental health can be avoided to a moderate degree by KMC. Due to a lack of methodological uniformity, different scales for outcome measurement, and discrepancies in intervention features, significantly high heterogeneity was detected. The authors need further larger-scale studies with a uniform study design to better predict the efficacy of KMC better.

Effect of the Kangaroo Mother Method after Preterm Delivery on Maternal Stress and Anxiety in the Context of the COVID-19 Pandemic-A Cohort Study

BACKGROUND

The kangaroo mother method (KMM) may benefit infants and mothers in many ways. However, few studies focused on its efficacy on maternal anxiety and stress, especially in the context of the COVID-19 pandemic.

OBJECTIVE

To examine the effect of the kangaroo mother method (KMM) on postnatal stress and anxiety in mothers of preterm infants in neonatal intensive care, in the context of the COVID-19 pandemic.

METHODS

A cohort study of two groups of 56 mother-infant dyads recruited from a neonatal intensive care unit was conducted. Two groups were compared in terms of the mean duration of KMM during the twelve days of the study: the intervention group (mean duration of more than ninety minutes per day) and the control group (less than ninety minutes). Maternal stress was measured using the Parental Stressor: Neonatal Intensive Care Unit (PSS: NICU) scale and STAI E/R questionnaire before and after intervention (KMM). Demographic and other maternal covariates were extracted from medical records. Daily NICU records were used to track the frequency and duration of KMM sessions.

RESULTS

Mothers of the intervention group scored lower on the PSS: NICU and STAI E/R, although no statistically significant differences were found (p > 0.05).

CONCLUSIONS

Contrary to research based on biological and physiological parameters in newborns or performed before the COVID-19 pandemic, the differences found in applying subjective scales in mothers in the context of the COVID-19 pandemic were not significant. Therefore, mothers' perception of physical contact with their preterm infants may not have been as positive due to their fear of transmitting COVID.

A Systematic Review of the Effects of Skin-to-Skin Contact on Biomarkers of Stress in Preterm Infants and Parents

BACKGROUND

Premature infants and their parents experience significant stress related to separation and lifesaving procedures. While evidence suggests that skin-to-skin contact (SSC) is a stress-reducing intervention for both neonates and parents, the mechanisms that underlie its efficacy are not well understood.

OBJECTIVE

Purpose of this systematic review is to summarize the current state of knowledge on changes in biomarkers (ie, oxytocin [OT], cortisol, hypoxanthine, xanthine, uric acid, and allantoin), associated with SSC in premature infants and parents, that may reflect physiologic responses to stress.

METHODS

A comprehensive literature search was conducted from 1990 to 2020. Studies were selected using prespecified inclusion and exclusion criteria.

RESULTS

Of the 175 studies identified, only 19 are included in this review. Ten studies evaluated only infants, 2 evaluated only parents, and 7 evaluated for changes in biomarkers in both infants and parents. Cortisol was the most common biomarker evaluated. While changes in infants' cortisol levels were highly variable, in 55% of the parent studies, parent cortisol levels decreased following SSC. In both parents and infants, OT levels decreased following SSC. Only 1 study found that allantoin levels were significantly lower in infants who received SSC.

IMPLICATIONS FOR PRACTICE AND RESEARCH

While evidence suggests the numerous benefits of SSC, additional research is needed to identify the optimal biomarker to determine the mechanisms that underlie these effects. The use of novel biomarkers (eg, gene expression changes microbiome) may provide new insights into the mechanisms that underlie the efficacy of SSC.Video Abstract available at:https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=48.

Therapeutic Alliance as Active Inference: The Role of Therapeutic Touch and Synchrony

Recognizing and aligning individuals' unique adaptive beliefs or "priors" through cooperative communication is critical to establishing a therapeutic relationship and alliance. Using active inference, we present an empirical integrative account of the biobehavioral mechanisms that underwrite therapeutic relationships. A significant mode of establishing cooperative alliances-and potential synchrony relationships-is through ostensive cues generated by repetitive coupling during dynamic touch. Established models speak to the unique role of affectionate touch in developing communication, interpersonal interactions, and a wide variety of therapeutic benefits for patients of all ages; both neurophysiologically and behaviorally. The purpose of this article is to argue for the importance of therapeutic touch in establishing a therapeutic alliance and, ultimately, synchrony between practitioner and patient. We briefly overview the importance and role of therapeutic alliance in prosocial and clinical interactions. We then discuss how cooperative communication and mental state alignment-in intentional communication-are accomplished using active inference. We argue that alignment through active inference facilitates synchrony and communication. The ensuing account is extended to include the role of (C-) tactile afferents in realizing the beneficial effect of therapeutic synchrony. We conclude by proposing a method for synchronizing the effects of touch using the concept of active inference.

Attachment- and Relationship-Based Interventions during NICU Hospitalization for Families with Preterm/Low-Birth Weight Infants: A Systematic Review of RCT Data

This study conducts a systematic review and meta-analysis of the randomized-controlled clinical trials (RCTs) of attachment- and relationship-based interventions in the NICU. A systematic search of the PubMed, MEDLINE, Embase (OVID), PsycINFO, and CINAHL databases and the Cochrane Database of Systematic Reviews was conducted in February 2021. Of the 32,904 studies examined, 15 were identified as relevant, and 10 RCTs were eligible for meta-analysis. Cochrane’s risk of bias tool was used to assess the quality of the trial reporting. Interventions were categorized as (1) parent–infant interactions, (2) parent education, and/or (3) support through qualitative synthesis. The attachment- or relationship-based intervention was effective in relieving maternal traumatic stress, maternal depression, infant weight growth, and infant development. Subgroup analyses suggested that interventions significantly improved sub-domains of mothers’ and children’s interactive behavior. Tailored, staged interventions may contribute to better health outcomes in preterm infants and their families.

Kangaroo mother care and skin-to-skin care in preterm infants in the neonatal intensive care unit: A bibliometric analysis

BACKGROUND

The desire to understand and the growing interest in research on the effects of kangaroo mother care in preterm infants in the neonatal intensive care unit have led to a significant increase in the number of manuscripts published in this field over the past decade. It is therefore necessary to regularly review the state of knowledge on this phenomenon in order to identify progress and constraints, to stimulate reflection, and to encourage progress in future research.

PURPOSE

The aim of this study was to determine the current state of scientific production in relation to kangaroo mother care in preterm infants in the neonatal intensive care unit through bibliometric analysis.

DATA SOURCES

This study presents a review of 212 published papers from the Scopus database (1990-2019).

DATA EXTRACTION

Two processing software applications were used: VOSviewer and SciMAT. In addition, through a keyword analysis, this study established the hot spot research trends to be developed in future work. The study adhered to the PRISMA-ScR guidelines for quality improvement studies as part of the EQUATOR network.

RESULTS

Our results show that research in this field is going through a time of high productivity and we could sort this growing body of work into different periods, highlighting the most important topics.The analysis shows that most research in this field is focused on five motor topics. These are: prematurity, male, psychology, intensive care neonatal, and major clinical study. The analysis also allowed us to identify four basic and cross-disciplinary topics that need to be developed and that emerge as future research directions: preterm infants, child-parent relations, child development, and skin-to-skin contact.

IMPLICATIONS FOR PRACTICE AND RESEARCH

The main contribution of this work is the creation of a knowledge map on the research in this field. This article provides information on how we can shape the future to provide optimal care for these infants and their parents.

Skin-to-skin contact to improve premature mothers' anxiety and stress state: A meta-analysis

Premature mothers present more anxiety and stress after delivery, which may be caused by mother–infant separation while hospitalised. Skin‐to‐skin contact (SSC), a mitigating factor for mother–infant separation, can benefit infants and mothers in many ways, but few studies focused on its efficacy on maternal anxiety and stress states. Therefore, this review aims to evaluate the effect of SSC on anxiety and stress. Comprehensive research was conducted in nine databases. Meta‐analysis was conducted to investigate the effect of SSC, and subgroup analyses were performed to explain the sources of heterogeneity. Eight randomised controlled trials with 728 participants were included, and SSC significantly reduced the level of anxiety ([standardised mean difference, SMD] −0.72; 95% CI −1.08 to −0.35) and stress state ([SMD] −0.84; 95% CI −1.59 to −0.09). One subgroup analysis revealed that SSC can relieve anxiety if performing SSC no less than 1 h per day ([SMD] −0.94; 95% CI −1.34 to −0.53). Another subgroup analysis suggested that applying SSC repeatedly and lasting less than 1 week ([SMD] −1.49; 95% CI −2.31 to −0.66) or for 1 week to 2 weeks ([SMD] −1.04; 95% CI −1.29 to −0.79) can significantly reduce maternal anxiety level but no significance if lasting over 2 weeks ([SMD] −0.33; 95% CI −0.67 to 0.01). SSC can effectively improve anxiety and stress states among premature mothers after delivery, and not definitive finding presents that only SSC that was performed no less than 60 min could improve postpartum anxiety states, while SSC alone was not as effective when carried out over 2 weeks.

Premature Birth and Developmental Programming: Mechanisms of Resilience and Vulnerability

The third trimester of pregnancy represents a sensitive phase for infant brain plasticity when a series of fast-developing cellular events (synaptogenesis, neuronal migration, and myelination) regulates the development of neural circuits. Throughout this dynamic period of growth and development, the human brain is susceptible to stress. Preterm infants are born with an immature brain and are, while admitted to the neonatal intensive care unit, precociously exposed to stressful procedures. Postnatal stress may contribute to altered programming of the brain, including key systems such as the hypothalamic-pituitary-adrenal axis and the autonomic nervous system. These neurobiological systems are promising markers for the etiology of several affective and social psychopathologies. As preterm birth interferes with early development of stress-regulatory systems, early interventions might strengthen resilience factors and might help reduce the detrimental effects of chronic stress exposure. Here we will review the impact of stress following premature birth on the programming of neurobiological systems and discuss possible stress-related neural circuits and pathways involved in resilience and vulnerability. Finally, we discuss opportunities for early intervention and future studies.

The Effect of Caregiver-Facilitated Pain Management Interventions in Hospitalized Patients on Patient, Caregiver, Provider, and Health System Outcomes: A Systematic Review

CONTEXT

Alternative pain management interventions involving caregivers may be valuable adjuncts to conventional pain management interventions.

OBJECTIVES

Use systematic review methodology to examine caregiver-facilitated pain management interventions in a hospital setting and whether they improve patient, caregiver, provider, or health system outcomes.

METHODS

We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and Scopus databases from inception to April 2020. Original research on caregiver-facilitated pain management interventions in hospitalized settings (i.e., any age) were included and categorized into three caregiver engagement strategies: inform (e.g., pain education), activate (e.g., prompt caregiver action), and collaborate (encourage caregiver's interaction with providers).

RESULTS

Of 61 included studies, most investigated premature (n = 27 of 61; 44.3%) and full-term neonates (n = 19 of 61; 31.1%). Interventions were classified as activate (n = 46 of 61; 75.4%), inform-activate-collaborate (n = 6 of 61; 9.8%), inform-activate (n = 5 of 61; 8.2%), activate-collaborate (n = 3 of 61; 4.9%), or inform (n = 1 of 61; 1.6%) caregiver engagement strategies. Interventions that included an activate engagement strategy improved pain outcomes in adults (18-64 years) (e.g., self-reported pain, n = 4 of 5; 80%) and neonates (e.g., crying, n = 32 of 41; 73.0%) but not children or older adults (65 years and older). Caregiver outcomes (e.g., pain knowledge) were improved by inform-activate engagement strategies (n = 3 of 3). Interventions did not improve provider (e.g., satisfaction) or health system (e.g., hospital length of stay) outcomes. Most studies were of low (n = 36 of 61; 59.0%) risk of bias.

CONCLUSION

Caregiver-facilitated pain management interventions using an activate engagement strategy may be effective in reducing pain of hospitalized neonates. Caregiver-facilitated pain management interventions improved pain outcomes in most adult studies; however, the number of studies of adults is small warranting caution pending further studies.

Effects of osteopathic treatment versus static touch on heart rate and oxygen saturation in premature babies: A randomized controlled trial

BACKGROUND

Osteopathic manipulative treatment (OMT) has been successfully tested in the context of preterm infants. No studies, however, have been conducted to investigate the OMT immediate effects on physiological measurements, such as partial oxygen saturation (SpO2) and heart rate (HR). The purpose of the present study was to assess the effect of osteopathic treatment on SpO2 and HR values and to compare it with 10 min of static touch.

MATERIALS AND METHODS

Ninety-six preterm infants (41 male), aged 33.5 weeks (±4.3) with mean weight at birth of 2067gr (±929) were recruited from the neonatal intensive care unit (NICU) of the Buzzi Hospital in Milan, and randomly allocated to two groups: OMT and Static Touch. Each protocol session consisted of: a) 5-min Pre-touch baseline recording, b) 10-min touch procedure, c) 5-min post-touch recording. Primary and secondary outcomes were, respectively, the baseline changes of HR and SpO2.

RESULTS

The 2 × 2 repeated measure ANOVA for HR showed a statistically significant effect (F (1,94) = 5.34; p < 0.02), revealing that the OMT group decreases the HR value at T2 (p = 0.006). In contrast, SpO2 analysis showed an increase of SpO2 value where the OMT group demonstrated higher values at T2 (p = 0.04).

CONCLUSION

Results from the present study suggest that a single osteopathic intervention may induce beneficial effects on preterm physiological parameters.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03833635 - Date: February 7, 2019.

The effect of skin-to-skin care on postpartum depression among mothers of preterm or low birthweight infants: A systematic review and meta-analysis

BACKGROUND

Mothers of preterm or low birthweight (LBW) infants are at two to three times greater risk of postpartum depression (PPD) than mothers of healthy infants, which may be partially due to mother-infant separation during hospitalization. Skin-to-skin care could protect against PPD among these vulnerable mothers. We examined the effect of skin-to-skin care on PPD among mothers of preterm or LBW infants through a systematic review and meta-analysis.

METHODS

We searched six peer-reviewed databases for prospective studies of skin-to-skin interventions that took place in neonatal intensive care units (NICUs), used a validated PPD tool, and were published in English between 1979 and 2017. Data were standardized and pooled using Hedges method in a quality-weighted meta-analysis.

RESULTS

Eight studies detailing seven interventions met inclusion criteria. Intervention characteristics varied with duration ranging from one week to over two months, skin-to-skin sessions ranging from 15 min to 1 h, and frequency ranging from thrice daily to thrice weekly. Five PPD tools were used predominantly as continuous measures. Meta-analysis demonstrated that skin-to-skin interventions were associated with a 1.04% reduction in standardized depression scores versus standard care (p < 0.001), though high heterogeneity was evident (I² = 82.4%, p < 0.001).

LIMITATIONS

Studies differed markedly with respect to design and intervention features, and were methodologically limited by using continuous depressive scores (not dichotomous PPD diagnoses) as the outcome.

CONCLUSIONS

Skin-to-skin care has a small protective effect on maternal depressive scores, however the clinical relevance of this finding is arguably minimal. Additional well-designed studies are warranted to conclusively assess the effects of skin-to-skin on PPD.

Kangaroo mother care and infant biopsychosocial outcomes in the first year: A meta-analysis

AIM

A systematic review and meta-analysis was conducted to examine the relationship between KMC and infant/toddler biopsychosocial outcomes.

METHOD

PubMed, MEDLINE (OvidSP), MEDLINE in Process (OvidSP), Embase (OvidSP), PsycINFO (OvidSP), and AMED (OvidSP) were searched. Observational studies and randomized control trials through October 2015 that investigated the association between KMC intervention and infant/toddler biopsychosocial outcomes were included. Studies with <10 participants, those using skin-to-skin only during painful procedures or only on the day of birth, and those that did not report quantitative outcomes were excluded. Data were extracted by two coders and estimates were examined using random-effects.

RESULTS

3177 studies were screened with 13 meeting inclusion criteria and representing 5 child outcomes (cognitive, motor, self-regulation, socio-emotional and temperament). Among LBW/premature neonates, KMC compared to conventional care was associated with improved infant self-regulation. Moderated effects were identified for cognitive (duration of KMC) and motor development (duration of KMC, country-level mortality ratio, and infant gender).

INTERPRETATIONS

KMC administered to vulnerable neonates during a sensitive period of brain development has a lasting impact on self-regulation skills later in infancy. Further research examining the longer-term effect of KMC on cognitive and motor development, socioemotional skills, and temperament is needed.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Depressed and non-depressed mothers' touching during social interactions with their infants

•

Depressed mothers engage in less touching that is playful and interactive in nature.

•

Depressed mothers touch their infants less during face-to-face interactions.

•

Nondepressed mothers maintain high levels of touch following a perturbation period.

•

Depressed mothers decrease playful/stimulating touch after a perturbation period.

•

Implications for intervention programs of early touch stimulation for at-risk dyads.

Touch is a critical channel of communication used by mothers to communicate and interact with their infants and to contribute to their infants’ socio-emotional development. The present study examined maternal touching in 41 mothers with and without depressive symptomatology. Mothers and their 4-month-old infants participated in the Still-Face (maternal emotional unavailability) and Separation (maternal physical unavailability) procedures. Maternal touching behaviours were video-recorded and coded using the Caregiver Infant Touch Scale (CITS). Results indicated that mothers with higher levels of depressive symptoms engaged in less touching following the perturbation period in the Still-Face procedure, whereas mothers with lower levels of depressive symptoms maintained stable levels of touching across both interaction periods. Mothers with higher levels of depressive symptoms displayed less playful/stimulating types of touching. Taken together, these results underscore the importance of touch and suggest key differences in touching behaviour between dyads with maternal depressive symptomatology and those without.

Enhancing sensory experiences for very preterm infants in the NICU: an integrative review

OBJECTIVE

Very preterm infants hospitalized in the neonatal intensive care unit (NICU) experience alterations in sensory experiences. Defining types, timing and frequency of sensory-based interventions that optimize outcomes can inform environmental modifications. The objective of this study was to conduct an integrative review on sensory-based interventions used with very preterm infants in the NICU to improve infant and parent outcomes.

STUDY DESIGN

The data sources include MEDLINE, CINAHL, Cochrane Library and Google Scholar. Studies were identified that used sensory-based interventions in the NICU with preterm infants born ⩽32 weeks gestation, were published in a peer-reviewed journal between 1995 and 2015, and measured outcomes related to infant and parent outcomes. Studies were extracted from electronic databases and hand-searched from identified reference lists.

RESULTS

Eighty-eight articles were identified (31 tactile, 12 auditory, 3 visual, 2 kinesthetic, 2 gustatory/olfactory and 37 multimodal). There was evidence to support the use of kangaroo care, music and language exposure, and multimodal interventions starting at 25 to 28 weeks postmenstrual age. These interventions were related to better infant development and lower maternal stress, but not all findings were consistent. Limitations included lack of consistent outcome measures, study quality and gaps in the literature.

CONCLUSIONS

Most research identified interventions that were done for short periods of time. It is unclear what the potential is for improving outcomes if positive sensory exposures occur consistently throughout NICU hospitalization. Until more research defines appropriate sensory-based interventions to use with infants born very preterm in the NICU, information from this review can be combined with expert opinion and parent/family values to determine best practice.

Skin-to-skin care for procedural pain in neonates

BACKGROUND

Skin-to-skin care (SSC), often referred to as 'kangaroo care' (KC) due to its similarity with marsupial behaviour of ventral maternal-infant contact, is one non-pharmacological intervention for pain control in infants.

OBJECTIVES

The primary objectives were to determine the effect of SSC alone on pain from medical or nursing procedures in neonates compared to no intervention, sucrose or other analgesics, or additions to simple SSC such as rocking; and to determine the effects of the amount of SSC (duration in minutes), method of administration (e.g. who provided the SSC) of SSC in reducing pain from medical or nursing procedures in neonatesThe secondary objectives were to determine the safety of SSC care for relieving procedural pain in infants; and to compare the SSC effect in different postmenstrual age subgroups of infants.

SEARCH METHODS

For this update, we used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 1); MEDLINE via PubMed (1966 to 25 February 2016); Embase (1980 to 25 February 2016); and CINAHL (1982 to 25 February 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials.

SELECTION CRITERIA

Studies with randomisation or quasi-randomisation, double- or single-blinded, involving term infants (≥ 37 completed weeks' postmenstrual age (PMA) to a maximum of 44 weeks' PMA and preterm infants (< 37 completed weeks PMA) receiving SSC for painful procedures conducted by healthcare professionals.

DATA COLLECTION AND ANALYSIS

The main outcome measures were physiological or behavioural pain indicators and composite pain scores. A mean difference (MD) with 95% confidence interval (CI) using a fixed-effect model was reported for continuous outcome measures. We included variations on type of tissue-damaging procedure, provider of care, and duration of SSC.

MAIN RESULTS

Twenty-five studies (n = 2001 infants) were included. Nineteen studies (n = 1065) used heel lance as the painful procedure, one study combined venepuncture and heel stick (n = 50), three used intramuscular injection (n = 776), one used 'vaccination' (n = 60), and one used tape removal (n = 50). The studies were generally strong and had low or uncertain risk of bias. Blinding of the intervention was not possible, making them subject to high risk, depending on the method of scoring outcomes.Seventeen studies (n = 810) compared SSC to a no-treatment control. Although 15 studies measured heart rate during painful procedures, data from only five studies (n = 161) could be combined for a mean difference (MD) of -10.78 beats per minute (95% CI -13.63 to -7.93) favouring SSC. Meta-analysis of four studies (n = 120) showed no difference in heart rate following the painful procedure (MD 0.08, 95% CI -4.39 to 4.55). Two studies (n = 38) reported heart rate variability with no significant differences. Two studies (n = 101) in a meta-analysis on oxygen saturation at 30 and 60 seconds following the painful procedure did not show a difference. Duration of crying meta-analysis was performed on four studies (n = 133): two (n = 33) investigated response to heel lance (MD = -34.16, 95% CI -42.86 to -25.45), and two (n = 100) following IM injection (MD = -8.83, 95% CI -14.63 to -3.02), favouring SSC. Five studies, one consisting of two substudies (n = 267), used the Premature Infant Pain Profile (PIPP) as a primary outcome, which favoured SCC at 30 seconds (MD -3.21, 95% CI -3.94 to -2.47), at 60 seconds (3 studies; n = 156) (MD -1.64, 95% CI -2.86 to -0.43), and at 90 seconds (n = 156) (MD -1.28, 95% CI -2.53 to -0.04); but at 120 seconds there was no difference (n = 156) (MD 0.07, 95% CI -1.11 to 1.25). No studies on return of heart rate to baseline level, cortisol levels, and facial actions could be combined for meta-analysis findings.Eight studies compared SSC to another intervention with or without a no-treatment control. Two cross-over studies (n = 80) compared mother versus other provider (father, another female) on PIPP scores at 30, 60, 90, and 120 seconds with no significant difference. When SSC was compared to other interventions, there were not enough similar studies to pool results in an analysis. One study compared SSC (n = 640) with and without dextrose and found that the combination was most effective and that SSC alone was more effective than dextrose alone. Similarly, in another study SSC was more effective than oral glucose for heart rate (n = 95). SSC either in combination with breastfeeding or alone was favoured over a no-treatment control, but not different to breastfeeding. One study compared SSC alone and in combination with both sucrose and breastfeeding on heart rate (HR), NIPS scores, and crying time (n = 127). The combinations were more effective than SSC alone for NIPS and crying. Expressed breast milk was compared to SSC in one study (n = 50) and found both equally effective on PIPP scores. There were not enough participants with similar outcomes and painful procedures to compare age groups or duration of SSC. No adverse events were reported in any of the studies.

AUTHORS' CONCLUSIONS

SSC appears to be effective as measured by composite pain indicators with both physiological and behavioural indicators and, independently, using heart rate and crying time; and safe for a single painful procedure. Purely behavioural indicators tended to favour SSC but with facial actions there is greater possibility of observers not being blinded. Physiological indicators were mixed although the common measure of heart rate favoured SSC. Two studies compared mother-providers to others, with non-significant results. There was more heterogeneity in the studies with behavioural or composite outcomes. There is a need for replication studies that use similar, clearly defined outcomes. Studies examining optimal duration of SSC, gestational age groups, repeated use, and long-term effects of SSC are needed. Of interest would be to study synergistic effects of SSC with other interventions.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

The role of gentle touch in perinatal osteopathic manual therapy

Osteopathic medicine is a system of manual diagnosis and treatment. While there is growing evidence that osteopathy is effective in a range of clinical conditions, the underlying biological basis of its therapeutic effects remain largely unknown. Given that the sense of touch plays a critical role in osteopathy, in this perspective article, with a particular focus on perinatal care, we explore the potential mechanisms by which stimulation of the skin senses can exert beneficial physiological and psychological effects, aiding growth and development. We propose that a class of low threshold mechanosensitive c-fibre, named c-tactile afferents, which respond optimally to gentle, slow moving touch are likely to play a direct and significant role in the efficacy of manual therapies. A greater understanding of the impact the type and quality of touch plays in therapeutic tactile interventions and in particular the neuroscience underpinning these effects will aid the development of more targeted, population specific interventions.

From Sweeping to the Caress: Similarities and Discrepancies between Human and Non-Human Primates' Pleasant Touch

Affective touch plays a key role in affiliative behavior, offering a mechanism for the formation and maintenance of social bonds among conspecifics, both in humans and non-human primates. Furthermore, it has been speculated that the CT fiber system is a specific coding channel for affiliative touch that occurs during skin-to-skin interactions with conspecifics. In humans, this touch is commonly referred to as the caress, and its correlation with the CT fiber system has been widely demonstrated. It has been hypothesized that the sweeping touch that occurs during grooming in non-human primates may modulate the CT fibers, with recent preliminary studies on rhesus monkeys supporting this hypothesis. The present mini-review proposes a comparison between the pleasant touch, caress and sweeping of humans and non-human primates, respectively. The currently available data was therefore reviewed regarding (i) the correlation between pleasant touch and CT fibers both in humans and non-human primates, (ii) the autonomic effects, (iii) the encoding at the central nervous system, (iv) the development from early life to adulthood, and (v) the potential applications of pleasant touch in the daily lives of both humans and non-human primates. Moreover, by considering both the similarities and discrepancies between the human caress and non-human primate sweeping, a possible evolutionary mechanism can be proposed that has developed from sweeping as a utilitarian action with affiliative meaning among monkeys, to the caress as a purely affective gesture associated with humans.

Kangaroo mother care to reduce morbidity and mortality in low birthweight infants

BACKGROUND

Kangaroo mother care (KMC), originally defined as skin-to-skin contact between a mother and her newborn, frequent and exclusive or nearly exclusive breastfeeding, and early discharge from hospital, has been proposed as an alternative to conventional neonatal care for low birthweight (LBW) infants.

OBJECTIVES

To determine whether evidence is available to support the use of KMC in LBW infants as an alternative to conventional neonatal care before or after the initial period of stabilization with conventional care, and to assess beneficial and adverse effects.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches in CENTRAL (Cochrane Central Register of Controlled Trials; 2016, Issue 6), MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), LILACS (Latin American and Caribbean Health Science Information database), and POPLINE (Population Information Online) databases (all from inception to June 30, 2016), as well as the WHO (World Health Organization) Trial Registration Data Set (up to June 30, 2016). In addition, we searched the web page of the Kangaroo Foundation, conference and symposia proceedings on KMC, and Google Scholar.

SELECTION CRITERIA

Randomized controlled trials comparing KMC versus conventional neonatal care, or early-onset KMC versus late-onset KMC, in LBW infants.

DATA COLLECTION AND ANALYSIS

Data collection and analysis were performed according to the methods of the Cochrane Neonatal Review Group.

MAIN RESULTS

Twenty-one studies, including 3042 infants, fulfilled inclusion criteria. Nineteen studies evaluated KMC in LBW infants after stabilization, one evaluated KMC in LBW infants before stabilization, and one compared early-onset KMC with late-onset KMC in relatively stable LBW infants. Sixteen studies evaluated intermittent KMC, and five evaluated continuous KMC. KMC versus conventional neonatal care: At discharge or 40 to 41 weeks' postmenstrual age, KMC was associated with a statistically significant reduction in the risk of mortality (risk ratio [RR] 0.60, 95% confidence interval [CI] 0.39 to 0.92; eight trials, 1736 infants), nosocomial infection/sepsis (RR 0.35, 95% CI 0.22 to 0.54; five trials, 1239 infants), and hypothermia (RR 0.28, 95% CI 0.16 to 0.49; nine trials, 989 infants; moderate-quality evidence). At latest follow-up, KMC was associated with a significantly decreased risk of mortality (RR 0.67, 95% CI 0.48 to 0.95; 12 trials, 2293 infants; moderate-quality evidence) and severe infection/sepsis (RR 0.50, 95% CI 0.36 to 0.69; eight trials, 1463 infants; moderate-quality evidence). Moreover, KMC was found to increase weight gain (mean difference [MD] 4.1 g/d, 95% CI 2.3 to 5.9; 11 trials, 1198 infants; moderate-quality evidence), length gain (MD 0.21 cm/week, 95% CI 0.03 to 0.38; three trials, 377 infants) and head circumference gain (MD 0.14 cm/week, 95% CI 0.06 to 0.22; four trials, 495 infants) at latest follow-up, exclusive breastfeeding at discharge or 40 to 41 weeks' postmenstrual age (RR 1.16, 95% CI 1.07 to 1.25; six studies, 1453 mothers) and at one to three months' follow-up (RR 1.20, 95% CI 1.01 to 1.43; five studies, 600 mothers), any (exclusive or partial) breastfeeding at discharge or at 40 to 41 weeks' postmenstrual age (RR 1.20, 95% CI 1.07 to 1.34; 10 studies, 1696 mothers; moderate-quality evidence) and at one to three months' follow-up (RR 1.17, 95% CI 1.05 to 1.31; nine studies, 1394 mothers; low-quality evidence), and some measures of mother-infant attachment and home environment. No statistically significant differences were found between KMC infants and controls in Griffith quotients for psychomotor development at 12 months' corrected age (low-quality evidence). Sensitivity analysis suggested that inclusion of studies with high risk of bias did not affect the general direction of findings nor the size of the treatment effect for main outcomes. Early-onset KMC versus late-onset KMC in relatively stable infants: One trial compared early-onset continuous KMC (within 24 hours post birth) versus late-onset continuous KMC (after 24 hours post birth) in 73 relatively stable LBW infants. Investigators reported no significant differences between the two study groups in mortality, morbidity, severe infection, hypothermia, breastfeeding, and nutritional indicators. Early-onset KMC was associated with a statistically significant reduction in length of hospital stay (MD 0.9 days, 95% CI 0.6 to 1.2).

AUTHORS' CONCLUSIONS

Evidence from this updated review supports the use of KMC in LBW infants as an alternative to conventional neonatal care, mainly in resource-limited settings. Further information is required concerning the effectiveness and safety of early-onset continuous KMC in unstabilized or relatively stabilized LBW infants, as well as long-term neurodevelopmental outcomes and costs of care.

Kangaroo Mother Care and Neonatal Outcomes: A Meta-analysis

CONTEXT

Kangaroo mother care (KMC) is an intervention aimed at improving outcomes among preterm and low birth weight newborns.

OBJECTIVE

Conduct a systematic review and meta-analysis estimating the association between KMC and neonatal outcomes.

DATA SOURCES

PubMed, Embase, Web of Science, Scopus, African Index Medicus (AIM), Latin American and Caribbean Health Sciences Information System (LILACS), Index Medicus for the Eastern Mediterranean Region (IMEMR), Index Medicus for the South-East Asian Region (IMSEAR), and Western Pacific Region Index Medicus (WPRIM).

STUDY SELECTION

We included randomized trials and observational studies through April 2014 examining the relationship between KMC and neonatal outcomes among infants of any birth weight or gestational age. Studies with <10 participants, lack of a comparison group without KMC, and those not reporting a quantitative association were excluded.

DATA EXTRACTION

Two reviewers extracted data on study design, risk of bias, KMC intervention, neonatal outcomes, relative risk (RR) or mean difference measures.

RESULTS

1035 studies were screened; 124 met inclusion criteria. Among LBW newborns, KMC compared to conventional care was associated with 36% lower mortality(RR 0.64; 95% [CI] 0.46, 0.89). KMC decreased risk of neonatal sepsis (RR 0.53, 95% CI 0.34, 0.83), hypothermia (RR 0.22; 95% CI 0.12, 0.41), hypoglycemia (RR 0.12; 95% CI 0.05, 0.32), and hospital readmission (RR 0.42; 95% CI 0.23, 0.76) and increased exclusive breastfeeding (RR 1.50; 95% CI 1.26, 1.78). Newborns receiving KMC had lower mean respiratory rate and pain measures, and higher oxygen saturation, temperature, and head circumference growth.

LIMITATIONS

Lack of data on KMC limited the ability to assess dose-response.

CONCLUSIONS

Interventions to scale up KMC implementation are warranted.

Effects of kangaroo mother care on maternal mood and interaction patterns between parents and their preterm, low birth weight infants: a systematic review

The birth of a premature infant can have adverse effects on the mood of mothers and on the interaction patterns between parents and their preterm babies. The aim of the present systematic review was to examine whether the Kangaroo Mother Care (KMC) intervention can attenuate these adverse psychological effects of a premature birth by ameliorating negative maternal mood and/or promoting more positive interactions between preterm infants and their parents. The results showed that although findings of studies were inconclusive, there is some evidence to suggest that KMC can make a positive difference on these areas. Specifically, it was found that KMC can improve negative maternal mood (e.g., anxiety or depression) and promote more positive parent-child interactions. Limitations and directions for future research are discussed.

A Meta-ethnography: Skin-to-Skin Holding From the Caregiver's Perspective

BACKGROUND

Although the benefits of skin-to-skin care (SSC) are well documented in the literature, practices in the clinical setting remain inconsistent. Although nurses' reported knowledge about SSC has improved, confusion still exists regarding safety and appropriateness. Existing qualitative literature primarily focuses on parents' experiences; yet it is crucial to describe the essence of professional caregivers' experiences to enhance facilitation and implementation of SSC. Most studies surrounding the caregiver's perspective and SSC have focused on barriers that impede implementation or examined the experience from the organizational perspective and general group experiences rather than individual personal experiences with SSC.

PURPOSE

This meta-ethnography integrated the findings from several discrete studies into a salient interpretative perspective, creating a relevant understanding of the process of SSC as a means of enhancing facilitation and implementation of SSC with hospitalized infants.

METHODS

An ethnographic meta-synthesis of qualitative literature was completed.

RESULTS

As a result of this synthesis, the caregivers' experiences were separated into themes to articulate the phenomena juxtaposed from the 8 original studies that influence facilitation of SSC for the parent-infant dyad. Qualitative data analysis uncovered 4 overarching themes: (1) varying thresholds of getting started; (2) defining adequate resources; (3) navigating the demands and complexity of the infant; and (4) balancing parental readiness with infant needs.

IMPLICATIONS FOR PRACTICE

This ethnographic meta-synthesis confirms nurses have good intentions in supporting SSC practices, yet struggle to meet competing demands in their daily practice.

IMPLICATIONS FOR RESEARCH

Innovative and practical translations of SSC are needed to normalize SSC as the daily standard for premature infants.

Understanding kangaroo care and its benefits to preterm infants

The holding of an infant with ventral skin-to-skin contact typically in an upright position with the swaddled infant on the chest of the parent, is commonly referred to as kangaroo care (KC), due to its simulation of marsupial care. It is recommended that KC, as a feasible, natural, and cost-effective intervention, should be standard of care in the delivery of quality health care for all infants, regardless of geographic location or economic status. Numerous benefits of its use have been reported related to mortality, physiological (thermoregulation, cardiorespiratory stability), behavioral (sleep, breastfeeding duration, and degree of exclusivity) domains, as an effective therapy to relieve procedural pain, and improved neurodevelopment. Yet despite these recommendations and a lack of negative research findings, adoption of KC as a routine clinical practice remains variable and underutilized. Furthermore, uncertainty remains as to whether continuous KC should be recommended in all settings or if there is a critical period of initiation, dose, or duration that is optimal. This review synthesizes current knowledge about the benefits of KC for infants born preterm, highlighting differences and similarities across low and higher resource countries and in a non-pain and pain context. Additionally, implementation considerations and unanswered questions for future research are addressed.

Kangaroo mother care to reduce morbidity and mortality in low birthweight infants

BACKGROUND

Kangaroo mother care (KMC), originally defined as skin-to-skin contact between a mother and her newborn, frequent and exclusive or nearly exclusive breastfeeding, and early discharge from hospital, has been proposed as an alternative to conventional neonatal care for low birthweight (LBW) infants.

OBJECTIVES

To determine whether there is evidence to support the use of KMC in LBW infants as an alternative to conventional neonatal care.

SEARCH METHODS

The standard search strategy of the Cochrane Neonatal Group was used. This included searches in MEDLINE, EMBASE, LILACS, POPLINE, CINAHL databases (all from inception to March 31, 2014) and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2014) In addition, we searched the web page of the Kangaroo Foundation, conference and symposia proceedings on KMC, and Google scholar.

SELECTION CRITERIA

Randomized controlled trials comparing KMC versus conventional neonatal care, or early onset KMC (starting within 24 hours after birth) versus late onset KMC (starting after 24 hours after birth) in LBW infants.

DATA COLLECTION AND ANALYSIS

Data collection and analysis were performed according to the methods of the Cochrane Neonatal Review Group.

MAIN RESULTS

Eighteen studies, including 2751 infants, fulfilled inclusion criteria. Sixteen studies evaluated KMC in LBW infants after stabilization, one evaluated KMC in LBW infants before stabilization, and one compared early onset KMC with late onset KMC in relatively stable LBW infants. Thirteen studies evaluated intermittent KMC and five evaluated continuous KMC. At discharge or 40-41 weeks' postmenstrual age, KMC was associated with a reduction in the risk of mortality (typical risk ratio (RR) 0.60, 95% confidence interval (CI) 0.39 to 0.92; eight trials, 1736 infants), nosocomial infection/sepsis (typical RR 0.45, 95% CI 0.27 to 0.76), hypothermia (typical RR 0.34, 95% CI 0.17 to 0.67), and length of hospital stay (typical mean difference 2.2 days, 95% CI 0.6 to 3.7). At latest follow up, KMC was associated with a decreased risk of mortality (typical RR 0.67, 95% CI 0.48 to 0.95; 11 trials, 2167 infants) and severe infection/sepsis (typical RR 0.56, 95% CI 0.40 to 0.78). Moreover, KMC was found to increase some measures of infant growth, breastfeeding, and mother-infant attachment. There were no significant differences between KMC infants and controls in neurodevelopmental and neurosensory impairment at one year of corrected age. Sensitivity analysis suggested that the inclusion of studies with high risk of bias did not affect the general direction of findings or the size of the treatment effect for the main outcomes.

AUTHORS' CONCLUSIONS

The evidence from this updated review supports the use of KMC in LBW infants as an alternative to conventional neonatal care mainly in resource-limited settings. Further information is required concerning effectiveness and safety of early onset continuous KMC in unstabilized or relatively stabilized LBW infants, long term neurodevelopmental outcomes, and costs of care.

Skin-to-skin care for procedural pain in neonates

BACKGROUND

Skin-to-skin care (SSC), otherwise known as Kangaroo Care (KC) due to its similarity with marsupial behaviour of ventral maternal-infant contact, is one non-pharmacological intervention for pain control in infants.

OBJECTIVES

The primary objectives were to determine the effect of SSC alone on pain from medical or nursing procedures in neonates undergoing painful procedures compared to no intervention, sucrose or other analgesics, or additions to simple SSC such as rocking; and the effects of the amount of SSC (duration in minutes) and the method of administration (who provided the SSC, positioning of caregiver and neonate pair).The secondary objectives were to determine the incidence of untoward effects of SSC and to compare the SSC effect in different postmenstrual age subgroups of infants.

SEARCH METHODS

The standard methods of the Cochrane Neonatal Collaborative Review Group were used. Databases searched in August 2011: Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library); Evidence-Based Medicine Reviews; MEDLINE (1950 onwards); PubMed (1975 onwards); EMBASE (1974 onwards); CINAHL (1982 onwards); Web of Science (1980 onwards); LILACS database (1982 onwards); SCIELO database (1982 onwards); PsycInfo (1980 onwards); AMED (1985 onwards); Dissertation-Abstracts International (1980 onwards). Searches were conducted throughout September 2012.

SELECTION CRITERIA

Studies with randomisation or quasi-randomisation, double or single-blinded, involving term infants (> 37 completed weeks postmenstrual age (PMA)) to a maximum of 44 weeks PMA and preterm infants (< 37 completed weeks PMA) receiving SSC for painful procedures conducted by doctors, nurses, or other healthcare professionals.

DATA COLLECTION AND ANALYSIS

The main outcome measures were physiological or behavioural pain indicators and composite pain scores. A weighted mean difference (WMD) with 95% confidence interval (CI) using a fixed-effect model was reported for continuous outcome measures. We included variations on type of tissue-damaging procedure, provider of care, and duration of SSC.

MAIN RESULTS

Nineteen studies (n = 1594 infants) were included. Fifteen studies (n = 744) used heel lance as the painful procedure, one study combined venepuncture and heel stick (n = 50), two used intramuscular injection, and one used 'vaccination' (n = 80). The studies that were included were generally strong and free from bias.Eleven studies (n = 1363) compared SSC alone to a no-treatment control. Although 11 studies measured heart rate during painful procedures, data from only four studies (n = 121) could be combined to give a mean difference (MD) of 0.35 beats per minute (95% CI -6.01 to 6.71). Three other studies that were not included in meta-analyses also reported no difference in heart rate after the painful procedure. Two studies reported heart rate variability outcomes and found no significant differences. Five studies used the Premature Infant Pain Profile (PIPP) as a primary outcome, which favoured SCC at 30 seconds (n = 268) (MD -3.21, 95% CI -3.94 to -2.48), 60 seconds (n = 164) (MD -1.85, 95% CI -3.03 to -0.68), and 90 seconds (n = 163) (MD -1.34, 95% CI -2.56 to -0.13), but at 120 seconds (n = 157) there was no difference. No studies provided findings on return of heart rate to baseline level, oxygen saturation, cortisol levels, duration of crying, and facial actions that could be combined for analysis.Eight studies compared SSC to another intervention with or without a no-treatment control. Two cross-over studies (n = 80) compared mother versus other provider on PIPP scores at 30, 60, 90, and 120 seconds with no significant difference. When SSC was compared to other interventions, there were not enough similar studies to pool results in an analysis. One study compared SSC with and without dextrose and found that the combination was most effective and that SSC alone was more effective than dextrose alone. Similarly, in another study SSC was more effective than oral glucose for heart rate but not oxygen saturation. SSC either in combination with breastfeeding or alone was favoured over a no-treatment control, but was not different to breastfeeding. There were not enough participants with similar outcomes and painful procedures to compare age groups or duration of SSC. No adverse events were reported in any of the studies.

AUTHORS' CONCLUSIONS

SSC appears to be effective, as measured by composite pain indicators and including both physiological and behavioural indicators, and safe for a single painful procedure such as a heel lance. Purely behavioural indicators tended to favour SSC but there remains questionable bias regarding behavioural indicators. Physiological indicators were typically not different between conditions. Only two studies compared mother providers to others, with non-significant results. There was more heterogeneity in the studies with behavioural or composite outcomes. There is a need for replication studies that use similar, clearly defined outcomes. New studies examining optimal duration of SSC, gestational age groups, repeated use, and long-term effects of SSC are needed.

Rethinking stress in parents of preterm infants: a meta-analysis

BACKGROUND

With improved medical outcome in preterm infants, the psychosocial situation of their families is receiving increasing attention. For parents, the birth of a preterm infant is generally regarded as a stressful experience, and therefore many interventions are based on reducing parental stress. Nevertheless, it remains unclear whether parents of children born preterm experience more stress than parents of term-born children, which would justify these interventions. This meta-analysis provides a comprehensive account of parental stress in parents of preterm infants, from birth of the infant through to their adolescence. Mean levels of stress in specific domains of family functioning were investigated, and stress levels in parents of preterm and term infants, and fathers and mothers of preterm infants, were compared. Furthermore, we investigated moderators of parental stress.

METHODS AND FINDINGS

A random-effects meta-analysis was conducted including 38 studies describing 3025 parents of preterm (<37 wk) and low birth weight (<2500 g) infants. Parental stress was measured with two parent-reported questionnaires, the Parenting Stress Index and the Parental Stressor Scale: Neonatal Intensive Care Unit. The results indicate that parents of preterm-born children experience only slightly more stress than parents of term-born children, with small effect sizes. Furthermore, mothers have slightly more stress than fathers, but these effect sizes are also small. Parents report more stress for infants with lower gestational ages and lower birth weights. There is a strong effect for infant birth year, with decreasing parental stress from the 1980s onward, probably due to increased quality of care for preterm infants.

CONCLUSIONS

Based on our findings we argue that prematurity can best be regarded as one of the possible complications of birth, and not as a source of stress in itself.

Initiation and extent of skin-to-skin care at two Swedish neonatal intensive care units

AIM

To describe initiation and extent of parents' application of skin-to-skin care (SSC) with their preterm infants at two Swedish neonatal intensive care units.

METHODS

The duration of SSC was recorded in 104 infants' medical charts during their hospital stay, and the parents answered a questionnaire.

RESULTS

Both parents were involved in the practice of SSC. Three infants experienced SSC directly after birth, 34 within 1 h, 85 within 24 h and the remaining 19 at 24-78 h postbirth. SSC commenced earlier (median age of 50 min) in infants whose first SSC was with their father instead of with their mother (median age of 649 min: p < 0.001). The earlier the SSC was initiated, the longer the infant was cared for skin-to-skin per day during his/her hospital stay (p < 0.001). The median daily duration of SSC was 403 min.

CONCLUSION

Early initiation of SSC had positive impact on the extent of parents' application of SSC. Even though the infants in this study were cared for skin-to-skin to a high extent, there is a potential for extended use of SSC in this type of hospital setting for reducing separation between infants and parents.

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

BACKGROUND

Mother-infant separation postbirth is common in Western culture. Early skin-to-skin contact (SSC) begins ideally at birth and involves placing the naked baby, head covered with a dry cap and a warm blanket across the back, prone on the mother's bare chest. According to mammalian neuroscience, the intimate contact inherent in this place (habitat) evokes neurobehaviors ensuring fulfillment of basic biological needs. This time may represent a psychophysiologically 'sensitive period' for programming future physiology and behavior.

OBJECTIVES

To assess the effects of early SSC on breastfeeding, physiological adaptation, and behavior in healthy mother-newborn dyads.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2011), made personal contact with trialists, and consulted the bibliography on kangaroo mother care (KMC) maintained by Dr. Susan Ludington.

SELECTION CRITERIA

Randomized controlled trials comparing early SSC with usual hospital care.

DATA COLLECTION AND ANALYSIS

We independently assessed trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

Thirty-four randomized controlled trials were included involving 2177 participants (mother-infant dyads). Data from more than two trials were available for only eight outcome measures. For primary outcomes, we found a statistically significant positive effect of early SSC on breastfeeding at one to four months postbirth (13 trials; 702 participants) (risk ratio (RR) 1.27, 95% confidence interval (CI) 1.06 to 1.53, and SSC increased breastfeeding duration (seven trials; 324 participants) (mean difference (MD) 42.55 days, 95% CI -1.69 to 86.79) but the results did not quite reach statistical significance (P = 0.06). Late preterm infants had better cardio-respiratory stability with early SSC (one trial; 31 participants) (MD 2.88, 95% CI 0.53 to 5.23). Blood glucose 75 to 90 minutes following the birth was significantly higher in SSC infants (two trials, 94 infants) (MD 10.56 mg/dL, 95% CI 8.40 to 12.72).The overall methodological quality of trials was mixed, and there was high heterogeneity for some outcomes.

AUTHORS' CONCLUSIONS

Limitations included methodological quality, variations in intervention implementation, and outcomes. The intervention appears to benefit breastfeeding outcomes, and cardio-respiratory stability and decrease infant crying, and has no apparent short- or long-term negative effects. Further investigation is recommended. To facilitate meta-analysis, future research should be done using outcome measures consistent with those in the studies included here. Published reports should clearly indicate if the intervention was SSC with time of initiation and duration and include means, standard deviations and exact probability values.

Kangaroo mother care to reduce morbidity and mortality in low birthweight infants

BACKGROUND

Kangaroo mother care (KMC), originally defined as skin-to-skin contact between a mother and her newborn, frequent and exclusive or nearly exclusive breastfeeding, and early discharge from hospital, has been proposed as an alternative to conventional neonatal care for low birthweight (LBW) infants.

OBJECTIVES

To determine whether there is evidence to support the use of KMC in LBW infants as an alternative to conventional neonatal care.

SEARCH STRATEGY

The standard search strategy of the Cochrane Neonatal Group was used. This included searches of MEDLINE, EMBASE, LILACS, POPLINE, CINAHL databases (from inception to January 31, 2011), and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2011). In addition, we searched the web page of the Kangaroo Foundation, conference and symposia proceedings on KMC, and Google scholar.

SELECTION CRITERIA

Randomized controlled trials comparing KMC versus conventional neonatal care, or early onset KMC (starting within 24 hours after birth) versus late onset KMC (starting after 24 hours after birth) in LBW infants.

DATA COLLECTION AND ANALYSIS

Data collection and analysis were performed according to the methods of the Cochrane Neonatal Review Group.

MAIN RESULTS

Sixteen studies, including 2518 infants, fulfilled inclusion criteria. Fourteen studies evaluated KMC in LBW infants after stabilization, one evaluated KMC in LBW infants before stabilization, and one compared early onset KMC with late onset KMC in relatively stable LBW infants. Eleven studies evaluated intermittent KMC and five evaluated continuous KMC. At discharge or 40 - 41 weeks' postmenstrual age, KMC was associated with a reduction in the risk of mortality (typical risk ratio (RR) 0.60, 95% confidence interval (CI) 0.39 to 0.93; seven trials, 1614 infants), nosocomial infection/sepsis (typical RR 0.42, 95% CI 0.24 to 0.73), hypothermia (typical RR 0.23, 95% CI 0.10 to 0.55), and length of hospital stay (typical mean difference 2.4 days, 95% CI 0.7 to 4.1). At latest follow up, KMC was associated with a decreased risk of mortality (typical RR 0.68, 95% CI 0.48 to 0.96; nine trials, 1952 infants) and severe infection/sepsis (typical RR 0.57, 95% CI 0.40 to 0.80). Moreover, KMC was found to increase some measures of infant growth, breastfeeding, and mother-infant attachment.

AUTHORS' CONCLUSIONS

The evidence from this updated review supports the use of KMC in LBW infants as an alternative to conventional neonatal care mainly in resource-limited settings. Further information is required concerning effectiveness and safety of early onset continuous KMC in unstabilized LBW infants, long term neurodevelopmental outcomes, and costs of care.

Randomized controlled trial of early skin-to-skin contact: effects on the mother and the newborn

OBJECTIVE

To estimate the influence of skin-to-skin care on the thermal regulation of the infant and the rate of breastfeeding at different points of time. We also aim to establish whether skin-to-skin contact reduces maternal pain during episiotomy repair and decreases the time to expel the placenta.

METHODS

A randomized control study was performed with 137 patients in each branch of the study. Differences between the study groups were analysed with the unpaired t-test, Fisher test or chi-square test as appropriate.

RESULTS

Greater thermal stability in the skin-to-skin care group was found where an average temperature rise of 0.07°C was observed. Mothers in the skin-to-skin care group exclusively breastfed more frequently at discharge. Mean time to expel the placenta was lesser in the skin-to-skin care group.

CONCLUSION

This study shows that skin-to-skin care implies better thermal regulation and a better proportion of exclusive breastfeeding at hospital discharge.

State of the art and recommendations. Kangaroo mother care: application in a high-tech environment

Since Kangaroo Mother Care (KMC) was developed in Colombia in the 1970s, two trends in clinical application emerged. In low income settings, the original KMC model is implemented. This consists of continuous (24 h/day, 7 days/week) and prolonged mother/parent-infant skin-to-skin contact; early discharge with the infant in the kangaroo position; (ideally) exclusive breastfeeding; and, adequate follow-up. In affluent settings, intermittent KMC with sessions of one or a few hours skin-to-skin contact for a limited period is common. As a result of the increasing evidence of the benefits of KMC for both infants and families in all intensive care settings, KMC in a high-tech environment was chosen as the topic for the first European Conference on KMC, and the clinical implementation of the KMC model in all types of settings was discussed at the 7th International Workshop on KMC. Kangaroo Mother Care protocols in high-tech Neonatal Intensive Care Units (NICU) should specify criteria for initiation, kangaroo position, transfer to/from KMC, transport in kangaroo position, kangaroo nutrition, parents' role, modification of the NICU environment, performance of care in KMC, and KMC in case of infant instability.

CONCLUSION

Implementation of the original KMC method, with continuous skin-to-skin contact whenever possible, is recommended for application in high-tech environments, although scientific evaluation should continue.

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

BACKGROUND

Keeping vulnerable preterm infants warm is problematic even when recommended routine thermal care guidelines are followed in the delivery suite.

OBJECTIVES

To assess efficacy and safety of interventions designed for prevention of hypothermia in preterm and/or low birthweight infants applied within 10 minutes after birth in the delivery suite compared with routine thermal care.

SEARCH STRATEGY

We used the standard search strategy of the Cochrane Neonatal Review Group (CNRG). The review was updated in October 2009.

SELECTION CRITERIA

Trials using randomised or quasi-randomised allocations to test a specific intervention designed to prevent hypothermia, (apart from 'routine' thermal care) applied within 10 minutes after birth in the delivery suite to infants of < 37 weeks' gestational age or birthweight </= 2500 g.

DATA COLLECTION AND ANALYSIS

We used the methods of the CNRG for data collection and analysis.

MAIN RESULTS

1) Barriers to heat loss [5 studies; plastic wrap or bag (3), plastic cap (1), stockinet cap (1)]:Plastic wraps or bags were effective in reducing heat losses in infants < 28 weeks' gestation (4 studies, n = 223; WMD 0.68 degrees C; 95% CI 0.45, 0.91), but not in infants between 28 to 31 week's gestation. Plastic caps were effective in reducing heat losses in infants < 29 weeks' gestation (1 study, n = 64; MD 0.80 degrees C; 95% CI 0.41, 1.19). There was insufficient evidence to suggest that either plastic wraps or plastic caps reduce the risk of death within hospital stay. There was no evidence of significant differences in other clinical outcomes for either the plastic wrap/bag or the plastic cap comparisons. Stockinet caps were not effective in reducing heat losses.2) External heat sources [2 studies; skin-to-skin (1), transwarmer mattress (1)]:Skin-to-skin care (SSC) was shown to be effective in reducing the risk of hypothermia when compared to conventional incubator care for infants (1 study, n = 31; RR 0.09; 95% CI 0.01, 0.64). The transwarmer mattress reduced the incidence of hypothermia on admission to NICU in VLBW infants (1 study, n = 24; RR 0.30; 95% CI 0.11, 0.83).

AUTHORS' CONCLUSIONS

Plastic wraps or bags, plastic caps, SSC and transwarmer mattresses all keep preterm infants warmer leading to higher temperatures on admission to neonatal units and less hypothermia. However, the small numbers of infants and studies and the absence of long-term follow-up mean that firm recommendations for clinical practice cannot be given.

Coregulation in Salivary Cortisol During Maternal Holding of Premature Infants

Purpose: The purpose of this study was to examine coregulation between mothers and preterm infants in hypothalamic-pituitary-adrenocortical (HPA) system activity, as indicated by salivary cortisol levels, while mothers held their infants. The research questions were (a) does mother—infant coregulation in HPA activity occur during holding? and (b) if mother— infant coregulation in HPA activity exists during holding, do type of holding, antenatal steroids, sound level, and maternal touch influence this coregulation? Sample: The sample consisted of 20 mother— infant dyads with infants at a mean postconceptional age of 34.7 weeks (+0.7) and average postnatal age of 15 days (+9) at the time of cortisol sampling. Design: The design was exploratory using convenience sampling. Maternal and infant cortisol levels were obtained at Time 1 (baseline) and Time 2 (end of holding); at each time, the absolute differences in levels between mother and infant were determined. Coregulation was operationalized as less difference between maternal-infant cortisol levels immediately after holding (Time 2) as compared to before holding (Time 1). Results: The two variables with the highest correlation with the Time 1/Time 2 difference score included antenatal steroids and ambient sound level, which were entered into a linear regression equation as predictor variables. A coregulatory relationship in cortisol levels existed between mothers and infants during holding, which was moderated by sound levels. Nurses in the neonatal intensive care unit (NICU) can facilitate the mother—infant relationship, as reflected in coregulatory measures, by promoting a quiet environment, particularly around mothers who are holding their infants.

Kangaroo Care (skin contact) reduces crying response to pain in preterm neonates: pilot results

Crying commonly occurs in response to heel stick and adversely affects the infant's physiologic stability. Minimal crying in response to pain is desired. "Kangaroo Care," skin contact between mother and infant, reduces pain and may reduce crying in response to pain. The purpose of this pilot study was to test Kangaroo Care's effect on the preterm infant's audible and inaudible crying response to heel stick. Inaudible crying has not been previously studied. A prospective randomized cross-over study with 10 preterm infants 2-9 days old (30-32 weeks' postmenstrual age) was conducted. Infants were randomly assigned to two sequences (sequence A: day 1 heel stick in Kangaroo Care [after 30 min of prone skin contact upright between maternal breasts] and day 2 heel stick in incubator [inclined, nested and prone]; or sequence B: opposite of sequence A) was conducted. Videotapes of baseline, heel warming, heel stick, and recovery phases were scored for audible and inaudible crying times. Audible and inaudible crying times for each subject in each phase were summed and analyzed by repeated-measures analysis of variance. Subject characteristics did not differ between those in the two sequences. Crying time differed between the study phases on both days (p <or= .001). When in Kangaroo Care compared with the incubator, crying time was less during the heel stick (p = .001) and recovery (p = .01) phases, regardless of sequence. Because Kangaroo Care reduced crying in response to heel stick in medically stable preterm infants, a definitive study is merited before making recommendations.

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

BACKGROUND

Hypothermia incurred during routine postnatal resuscitation is a world-wide issue (across all climates), associated with morbidity and mortality. Keeping vulnerable preterm infants warm is problematic even when recommended routine thermal care guidelines are followed in the delivery suite.

OBJECTIVES

To assess efficacy and safety of interventions designed for prevention of hypothermia in preterm and/or low birthweight infants applied within ten minutes after birth in the delivery suite compared with routine thermal care.

SEARCH STRATEGY

The standard search strategy of The Cochrane Collaboration was followed. Electronic databases were searched: MEDLINE (1966 to July Week 4 2007 ), CINAHL (1982 to July Week 4 2007), EMBASE (1974 to 01/08/2007), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2007), Database of Abstracts of Reviews of Effects (DARE 1994 to July 2007), conference/symposia proceedings using ZETOC (1993 to 17/08/2007), ISI proceedings (1990 to 17/08/2007) and OCLC WorldCat (July 2007). Identified articles were cross-referenced. No language restrictions were imposed.

SELECTION CRITERIA

All trials using randomised or quasi-randomised allocations to test a specific intervention designed to prevent hypothermia, (apart from 'routine' thermal care) applied within 10 minutes after birth in the delivery suite to infants of < 37 weeks' gestational age or birthweight </=2500 g.

DATA COLLECTION AND ANALYSIS

Methodological quality was assessed and data were extracted for important clinical outcomes including adverse effects of the intervention by at least three independent review authors. Authors were contacted for missing data. Data were analysed using RevMan 4.2.5. Relative risk (RR), risk difference (RD) and number needed to treat (NNT) with 95% confidence limits were calculated for each dichotomous outcome and mean differences (MD) with 95% confidence limits for continuous outcomes.

MAIN RESULTS

Six studies giving a total of 304 infants randomised and 295 completing the studies were included. Four comparisons to 'routine care' were undertaken within two categories:1) barriers to heat loss (four studies): plastic wrap or bag (three), stockinet caps (one) and2) external heat sources (two studies): skin-to-skin (one), transwarmer mattress (one). Plastic barriers were effective in reducing heat losses in infants < 28 weeks' gestation (three studies, n = 159; WMD 0.76 degrees C; 95% CI 0.49, 1.03), but not in infants between 28 to 31 week's gestation. There was insufficient evidence to suggest that plastic wrap reduces the risk of death within hospital stay (three studies, n = 161; typical RR 0.63; 95% CI 0.32, 1.22; typical RD -0.09; 95% CI -0.20, 0.03). There was no evidence of a significant difference in major brain injury, mean duration of oxygen therapy or hospitalisation for infants < 29 weeks' gestation. Stockinet caps were not effective (borderline significant for infants < 2000 g birthweight) in reducing heat losses.Skin-to-skin care was shown to be effective in reducing the risk of hypothermia when compared to conventional incubator care for infants 1200 to 2199 g birthweight (one study, n = 31; RR 0.09; 95% CI 0.01, 0.64; NNT 2; 2 to 4). The transwarmer mattress kept infants </=1500 g significantly warmer and reduced the incidence of hypothermia on admission to NICU(one study, n = 24; RR 0.30; 95% CI 0.11, 0.83; NNT 2 range 2 to 4).

AUTHORS' CONCLUSIONS

Plastic wraps or bags, skin-to-skin care and transwarmer mattresses all keep preterm infants warmer, leading to higher temperatures on admission to neonatal units and less hypothermia. Given the low NNT, consideration should be given to using these interventions in the delivery suite. However, the small numbers of infants and studies and the absence of long-term follow-up mean that firm recommendations for clinical practice cannot be given. There is a need to conduct large, high quality randomised controlled trials looking at long-term outcomes.

The development of potentially better practices to support the neurodevelopment of infants in the NICU

OBJECTIVE

To review the existing evidence used to identify potentially better care practices that support newborn brain development.

STUDY DESIGN

Literature review.

RESULT

Sixteen potentially better practices are identified and grouped into two operational clinical bundles based upon timing for recommended implementation.

CONCLUSION

Existing evidence supports the implementation of selected care practices that potentially may support newborn brain development.

Kognitive Entwicklung und sozial-emotionale Kompetenzen bei Frühgeborenen mit unterschiedlichen Bindungsrepräsentationen

Zusammenfassung. Es wurde geprüft, ob sich frühgeborene und termingeborene Kinder im Vorschulalter in ihrer kognitiven Entwicklung und ihren sozial-emotionalen Kompetenzen unterscheiden. Insgesamt wurden 29 Kinder im Alter zwischen fünf und sechs Jahren im Hinblick auf die Faktoren “Geburtszeitpunkt” (Frühgeborene < 2000 g vs. Termingeborene > 2600 g) und “Bindungsqualität” (sicher vs. unsicher gebunden) untersucht. Die Bindungsqualität wurde auf der Repräsentationsebene durch das Geschichtenergänzungsverfahren zur Bindung (GEV-B) erfasst. Die kognitive Leistung und sozial-emotionale Entwicklung wurde mit dem Entwicklungstest ET 6-6 sowie die emotionale Kompetenz durch den Untertest “Fotoalbum” des WET und die sozial-emotionalen Kompetenzen durch einen Erzieherbeobachtungsbogen erhoben. Frühgeborene erzielten signifikant niedrigere Werte in den Dimensionen der kognitiven Entwicklung des ET 6-6 als termingeborene Kinder. Außerdem bewerteten Erzieher das Sozialverhalten der Frühgeborenen tendenziell als weniger kompetent verglichen mit dem Verhalten der Termingeborenen. Im Untertest “Fotoalbum” des WET konnten unsicher gebundene Kinder im Vergleich zu sicher gebundenen Kindern emotionale Gesichtsausdrücke tendenziell schlechter erkennen. Diese Ergebnisse sprechen dafür, dass sich der Faktor “Frühgeburt” insbesondere auf die kognitive Leistung auswirkt.