Effects of skin-to-skin care on electrical activity of the diaphragm in preterm infants during neurally adjusted ventilatory assist

Review of Low-Cost Interventions for Reducing Neonatal Mortality and Morbidity in Low- and Middle-Income Countries

AIM

This review examines low-cost interventions for reducing neonatal mortality and morbidity in low- and middle-income countries (LMICs).

METHODS

A systematic PubMed search and neonatal care data from World Health Organization (2014-2024) were used to revise interventions including prenatal care, early essential newborn care (EENC), resuscitation and therapeutic hypothermia, Kangaroo mother care (KMC), respiratory support, breastfeeding, sepsis prevention, safe neonatal transfer, neonatal network in LMICs and suggestions for improvement. Out of 9295 initially identified articles, 252 studies were selected as relevant to the research objectives.

RESULTS

In LMICs, the use of antenatal corticosteroids and magnesium sulfate remains limited in routine obstetric practice. Although EENC, KMC and early breastfeeding significantly reduce neonatal mortality, these interventions are under-prioritised and insufficiently implemented. Neonatal resuscitation and respiratory support are constrained by inadequate equipment and a shortage of trained healthcare personnel. Healthcare-associated sepsis, compounded by antibiotic resistance, continues to strain neonatal intensive care units. Additionally, unsafe neonatal transfers and poor coordination among different levels of neonatal care highlight the need for better integration within regional health systems.

CONCLUSIONS

To reduce neonatal mortality and enhance care in LMICs, systematic training, effective implementation and the sustainable delivery of proven, low-cost, high-impact interventions are urgently needed.

A Staff Educational Intervention to Increase the Time of Skin-to-Skin Care in a Swedish NICU: A Quality Improvement Project

BACKGROUND

Skin-to-skin contact (SSC) is crucial in neonatal intensive care unit (NICU) care; yet, challenges exist in its implementation. This study addresses a knowledge gap by examining the most effective ways to introduce SSC in the NICU, emphasizing the need to seamlessly integrate this practice for optimal infant and parent care. One way, among many, to implement SSC is to increase staff's knowledge and awareness about SSC.

OBJECTIVE

To describe the effect of an educational intervention on SSC time, the number of SSC sessions per day, and the number of infants cared for with SSC within their first day of life.

METHODS

A pre- and postinterventional study design was used to determine the effect of an educational intervention on SSC time, the number of SSC sessions per day, and the number of infants cared for with SSC within their first day of life.

RESULTS

The prevalence of infants receiving SSC during their first 24 hours of life, the number of SSC sessions per day, and the duration of each SSC session increased after the intervention, and these effects persisted over 2 years.

IMPLICATIONS FOR PRACTICE

Our study highlights the impact of staff education and reflective discussions on SSC in the NICU. Integrating these with practical training, parental education, and NICU environment modifications is pivotal for enhancing and sustaining optimal SSC practices, benefiting both infants and parents.

The impact of skin-to-skin contact upon stress in preterm infants in a neonatal intensive care unit

Introduction

Neonatal stress significantly affects the early adaptation, maturation and long-term development of preterm infants.

The objective of the study

To investigate the effect of skin-to-skin contact (SSC) on stress level in preterm infants.

Materials and methods

The research was a prospective study. Stress indicators (cortisol, melatonin) were measured before the SSC began (pre-intervention level) and after this intervention (post-intervention).

Results

The study included 150 preterm infants in the NICU with gestational age (GA) ≤36 weeks. Pre-intervention salivary cortisol level was higher in extremely and very preterm neonates compared to moderate and late preterm newborns (p = 0.028), in children with low Apgar scores (p = 0.041), in those who were on mechanical ventilation (p = 0.005), and suffered neonatal sepsis (p = 0.005). Pre-intervention melatonin level was lower in children with low Apgar scores (p = 0.032). Salivary cortisol levels were significantly decreased after SSC in preterm infants [pre-intervention: 0.294 (0.111; 0.854) μg/dL vs. post-intervention: 0.127 (0.070; 0.229) μg/dL, p < 0.001], and urinary melatonin levels were significantly increased after SSC [pre-intervention: 4.01 (2.48; 6.34) ng/mL vs. post-intervention: 5.48 (3.39; 9.17) ng/mL, p < 0.001]. A greater reduction in cortisol levels after skin-to-skin contact was revealed in infants with a lower gestational age (p = 0.022), in boys compared to girls (p = 0.012), in infants with respiratory distress syndrome (p = 0.048), in those who had mechanical ventilation compared to non-ventilated neonates (p = 0.008), and in infants with seizures (p = 0.036). The melatonin levels increased more intensively in infants with low Apgar scores (p = 0.002), and in those with late-onset sepsis (p = 0.006).

Conclusion

The reduction in cortisol levels and the increase in melatonin levels provided strong evidence that SSC ameliorated the NICU-related stress in preterm infants. We found higher indicators of stress and more dramatic responses to SSC in reducing indicators of stress in infants with lower GA than in infants with higher GA, indicating that SSC may be even more important for lower GA infants. The infants who need SSC the most should not be denied the care they need to reduce the stress they experience from being born too soon and continuing their gestational development in the stressful environment of the NICU.

Skin-to-Skin Contact and Diaphragm Electrical Activity in Preterm Infants During Noninvasive Pressure Control

BACKGROUND

Skin-to-skin contact (SSC) is widely implemented in the neonatal intensive care unit (NICU) due to its established role in reducing mortality and morbidity. However, the impact of SSC on diaphragmatic electrical activity (Edi) in premature infants undergoing noninvasive pressure control (NIV-PC) for respiratory management remains insufficiently explored.

PURPOSE

To assess the effects of SSC on Edi and vital signs in preterm infants managed with NIV-PC.

METHODS

A prospective, observational, crossover study was conducted, involving preterm infants admitted to a level III NICU between May 2020 and August 2021, who were receiving respiratory support with NIV-PC. Data were collected at 3 distinct time points: before SSC (pre-SSC period), during SSC (SSC period), and after SSC (post-SSC period). Thirty-minute periods of stable data were extracted for analysis.

RESULTS

A total of 21 SSC sessions were performed on 14 preterm infants, with a median age at the initiation of SSC of 62 days. The median (interquartile range) Edi peak (in microvolts) before, during, and after SSC was 7.1 (5.8-10.8), 6.8 (4.3-8.8), and 7.1 (5.5-8.8), respectively. No statistically significant differences were observed in Edi peak or minimum values during SSC, when compared with the periods before and after the SSC procedure. Likewise, no significant changes were noted in respiratory rate, oxygen saturation, heart rate, or the incidence of apnea.

IMPLICATIONS FOR PRACTICE AND RESEARCH

SSC in preterm infants undergoing NIV-PC does not exacerbate their clinical condition. Further investigations involving diverse patient cohorts are warranted.

Improved respiratory parameters with skin-to-skin contact in premature infants with bronchopulmonary dysplasia on NIV-NAVA

AIM

To determine if skin-to-skin contact (SSC) improved respiratory parameters in premature infants with evolving or established bronchopulmonary dysplasia (BPD) on non-invasive neutrally adjusted ventilator assist (NIV-NAVA).

METHODS

Premature infants (<32 weeks gestational age) with BPD on NIV-NAVA were studied. Continuous readings from the Edi catheter (modified nasogastric feeding tube inserted for NAVA ventilation) were compared: pre-SSC (baby in incubator) and end-SSC (just before end of SSC).

RESULTS

Sixty-five episodes of SSC were recorded in 12 premature infants with median gestational age at birth of 24.4 (23.1-27.0) weeks and birth weight of 642 (530-960) grams. Peak Edi (uV) in end-SSC 11.5 (2.7-38.7) was significantly lower compared to pre-SSC 15.8 (4.0-36.6), p < 0.001. P mean (cmH₂ O) was significantly lower in end-SSC 9.7 (7.3-15.4) compared to pre-SSC 10.3 (7.5-15.5), p = 0.008. Respiratory rate (breaths/min) was significantly lower in end-SSC 52.9 (31.1-78.1) compared to pre-SSC 53.4 (35.1-74.1), p = 0.031. There was no significant difference in inspired oxygen requirement or time on back-up mode in end-SSC 40.0 (22.1-56.1) and 5.9 (0.0-56.0) compared to pre-SSC 39.0 (26.0-56.1) and 5.1 (0.0-29.3), p = 0.556 and p = 0.853 respectively.

CONCLUSION

SSC improved respiratory parameters in premature infants with evolving or established BPD on NIV-NAVA.

NIV-NAVA versus NCPAP immediately after birth in premature infants: A randomized controlled trial

OBJECTIVE

To evaluate whether noninvasive-neurally adjusted ventilatory assist (NIV-NAVA) decrease respiratory efforts compared to nasal continuous positive airway pressure (NCPAP) during the first hours of life.

METHODS

Twenty infants born between 28⁺⁰ and 31⁺⁶ weeks were randomized to NIV-NAVA or NCPAP. Positive end-expiratory pressure was constantly kept at 6 cmH₂O for both groups and the NAVA level was 1.0 cmH₂O/µV for NIV-NAVA group. The electrical activity of diaphragm (Edi) were recorded for the first two hours.

RESULTS

Peak and minimum Edi decreased similarly in both groups (P = 0.98 and P = 0.59, respectively). Leakages were higher in the NIV-NAVA group than in the NCPAP group (P < 0.001). The neural apnea defined as a flat Edi for ≥ 5 s were less frequent in NIV-NAVA group than in NCPAP group (P = 0.046).

CONCLUSIONS

Immediately applied NIV-NAVA in premature infants did not reduce breathing effort, measured as peak Edi. However, NIV-NAVA decreased neural apneic episodes compared to NCPAP.

Skin-to-Skin Contact and the Incidence of Transient Tachypnea of the Newborn

OBJECTIVES

To compare the incidence of transient tachypnea of the newborn (TTN) before and after the implementation of a Baby-Friendly protocol and to determine changes in the rates of TTN symptoms, interventions, completion of skin-to-skin contact.

DESIGN

Retrospective cohort study using data in the electronic medical record.

SETTING

Community-based tertiary obstetric facility.

PARTICIPANTS

We reviewed 934 charts of neonates born at or greater than 34 weeks gestation to women ages 18 years or older and included 790 neonates: 491 in the preimplementation group and 299 in the postimplementation group. Group assignment was based on time of Baby-Friendly protocol implementation. The preimplementation group included neonates born in April, August, and December of 2014, and the postimplementation group included neonates born during these months in 2018.

METHODS

The primary outcome was incidence of TTN. Secondary outcomes were rates of the following: tachypnea symptoms, hypoglycemia, antibiotic administration, and completion of skin-to-skin contact.

RESULTS

The incidence of TTN was 2% (n = 8/491) in the preimplementation group and 1% (n = 4/299) in the postimplementation group (p = 1.000). The rate of tachypnea symptoms decreased from 5% (n = 25/491) to 1% (n = 3/299, p = .003), the rate of hypoglycemia decreased from 11% (n = 54/491) to 3% (n = 10/299, p < .001), and the rate of antibiotic administration decreased from 13% (n = 66/491) to 4% (n = 11/299, p < .001). The skin-to-skin completion rate increased from 16% (n = 79/491) to 61% (n = 183/299, p < .001).

CONCLUSION

Although skin-to-skin contact facilitates physiologic transition to extrauterine life, incidence of TTN was not significantly reduced after the implementation of the Baby-Friendly protocol. However, increased practice of skin-to-skin contact was an improvement in care with implications for the transition to extrauterine life.