Meta-analysis of physiological effects of skin-to-skin contact for newborns and mothers

Effect of kangaroo mother care on cerebral oxygenation, physiological parameters, and comfort levels in late-premature infants: A randomized controlled trial

OBJECTIVE

To measure the effects kangaroo mother care (KMC) on the regional cerebral oxygen saturation (rSO2) measured with near-infrared spectroscopy (NIRS) in premature infants and to study the physiological stability and comfort of the infants during such interventions.

DESIGN

This was a prospective, single-centered, single-blind, 2-arm, parallel-group randomized controlled trial conducted.

SETTINGS

The study was carried out in a tertiary neonatal intensive care unit in Medical Faculty Hospital in Konya/Turkey.

PARTICIPANTS

Premature infants born between 24 and 36+6 weeks. Participants were randomly assigned to one of two groups: kangaroo care (n = 20) and control groups (n = 20). The rSO2, oxygen saturation (%SpO2), heart rate (HR), respiratory rate, body temperature, and comfort levels of the infants were evaluated in three stages.

FINDINGS

In the 60th min measurement of the intervention group, rSO2, body temperature, heart rate, respiratory rate, and, comfort level, the comfort level was found to be higher and significant in the 30th and 60th min measurements (p < 0.001). In the intervention group, the rSO2 (p < 0.001), body temperature (p < 0.001), HR (p < 0.001), SpO2 (p < 0.001), respiratory rate (p < 0.001), and comfort levels (p < 0.001) scores with the control group and the group × time interaction was significant.

KEY CONCLUSIONS

KMC moderately increased the rSO2 levels and also created a moderate effect size on the physiological parameters and comfort levels of the newborns, which implicates its short-term benefits for premature infants.

PRACTICE IMPLICATIONS

KMC may be beneficial in stabilizing rSO2 and physiological parameters and increasing comfort in premature infants. The trial was registered in ClinicalTrials.gov (identifier: NCT04725435).

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

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

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

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

Level of skin-to-skin care practices among postnatal mothers in Ethiopia. A systematic review and meta-analysis

Introduction

Even though skin-to-skin contact offers several advantages for the survival of the newborn, it is not often practiced in Ethiopia. For instance, hypothermia which increases the risk of neonatal mortality by five times is prevented by this practice. Despite this, there are inconsistent findings that can affect policymaking. Consequently, this metanalysis aimed to produce trustworthy national data regarding skin-to-skin care practice and its determinants among postpartum mothers in Ethiopia.

Methods

A search of the publications was conducted using MEDLINE, PubMed, Embase, Scopus, Web of Sciences, and Google Scholar. The program used for cleaning and analysis was STATA version 18.2. The random-effects model was utilized to estimate the pooled prevalence, which was then presented using a forest plot with a 95 % confidence interval. We evaluated heterogeneity using I2 and Cochrane Q statistics. Moreover, a visual examination of a funnel plot and Egger's regression test were used to evaluate publication bias.

Results

This study included eight studies with a total of 10410 postpartum mothers. The overall level of skin-to-skin care practices was 48 % (95%CI: 31, 65. I2=99.38 %, P = 0.001). Based on subgroup analysis by year of publication, studies published between 2017 and 2019 years showed that the level of skin-to-skin care practice among postnatal mothers was 52 % (95 % CI: 14-89, I2 = 99.19). The knowledge of mothers about skin-to-skin care was significantly associated with practicing a level of skin-to-skin care.

Conclusions

The findings showed that in Ethiopia, comparatively less than half of the newborns received skin-to-skin care. Moreover, there was a substantial correlation between the mother's knowledge and practice of skin-to-skin care. Therefore, both the government and all stakeholders should take coordinated action to improve and expand skin-to-skin care practices through health education, so that all postnatal mothers can practice this vital newborn care.

Effects of skin-to-skin contact in supported diagonal flexion positioning on movement quality in very preterm infants at term age

BACKGROUND

Preterm birth is associated with a high risk of long-term neuromotor disabilities such as coordination of movements, deficient antigravity limb movement, less adaptive postural control strategies, head deformities… AIMS: The aim of the present study was to examine the potential positive impact of a Supported Diagonal Flexion (SDF) skin-to-skin contact (SSC) positioning on the neuromotor development and movement quality of very preterm infants at term age.

STUDY DESIGN

Monocentric prospective matched-pair case-control study.

SUBJECTS

Thirty very preterm infants and their mother were proposed either SDF SSC positioning (n = 15) or Vertical SSC positioning (n = 15).

OUTCOME MEASURES

Amiel-Tison Neurological Assessment at Term (ATNAT) and observation of the spontaneous motor activity were assessed at term corrected age.

RESULTS

Infants in the SDF group had less dolichocephaly (adj. p = .014) and arms in candlestick position (adj. p = .048). Only 3 in the SDF group against 11 in the vertical group showed nonoptimal spontaneous motor activity. Infants in the SDF group had more positive signs such as foot-to-foot contact (adj. p = .047) or arms movements toward midline (adj. p = .046 and 0.011).

CONCLUSIONS

The present study shows that nonoptimal spontaneous motor activity was increased and dolichocephaly was more common in the vertical group. Consistently with current guidelines, it is critical to consider preterm infants' postures during SSC or while in incubators or cradles.

Improving the Treatment of Neonatal Sepsis in Resource-Limited Settings: Gaps and Recommendations

Neonatal sepsis causes significant global morbidity and mortality, with the highest burden in resource-limited settings where 99% of neonatal deaths occur. There are multiple challenges to achieving successful treatment of neonates in this setting. Firstly, reliable and low-cost strategies for risk identification are urgently needed to facilitate treatment as early as possible. Improved laboratory capacity to allow identification of causative organisms would support antimicrobial stewardship. Antibiotic treatment is still hampered by availability, but also increasingly by antimicrobial resistance - making surveillance of organisms and judicious antibiotic use a priority. Finally, supportive care is key in the management of the neonate with sepsis and has been underrecognized as a priority in resource-limited settings. This includes fluid balance and nutritional support in the acute phase, and follow-up care in order to mitigate complications and optimise long-term outcomes. There is much more work to be done in identifying the holistic needs of neonates and their families to provide effective family-integrated interventions and complete the package of neonatal sepsis management in resource-limited settings.

The effect of kangaroo mother care or skin-to-skin contact on infant vital signs: A systematic review and meta-analysis

BACKGROUND

It has been reported that kangaroo mother care/skin-to-skin contact immediately after birth facilitates the newborn's physiological and psychological adaptation to extrauterine life.

OBJECTIVE

To examine the effect of kangaroo mother care/skin-to-skin contact on infants' body temperature, oxygen saturation, respiratory rate and heart rate.

DESIGN

Systematic review and meta-analysis.

METHODS

PubMed, ScienceDirect, SpringerLink, Wiley Online Library and Taylor & Francis Online were searched for the period 1 January 2015 to 30 November 2021 for studies published in the English language. The methodological quality of articles was assessed using the modified Jadad scale and the Newcastle-Ottawa scale. Effect size calculations were made using the fixed effects and random effects models.

FINDINGS

This meta-analysis included 13 studies, with a total of 891 infants. Kangaroo mother care/skin-to-skin contact was effective for maintaining infants' body temperature (p = 0.000). Infants' heart rate decreased (p = 0.015) and oxygen saturation was higher (p = 0.040) following kangaroo mother care/skin-to-skin contact. Kangaroo mother care/skin-to-skin contact did not affect infants' respiratory rate (p = 0.896), but infants' respiratory rate decreased after kangaroo mother care/skin-to-skin contact (p = 0.047).

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Kangaroo mother care/skin-to-skin contact is effective for improving the vital signs of newborns. Kangaroo mother care/skin-to-skin contact is recommended for all neonates, and standardization of this approach would be beneficial.

The effects of kangaroo mother care on physiological parameters of premature neonates in neonatal intensive care unit: A systematic review

PURPOSE

The effects of Kangaroo mother care (KMC) on physiological parameters in preterm infants have been reported in the literature by experimental and quasi-experimental studies, and varying findings have been presented. The present study was conducted to determine the effects of KMC on the physiological parameters of premature newborns in the Neonatal Intensive Care Unit.

DESIGN AND METHOD

The review was conducted according to the specified keywords by scanning the EBSCO-host, Cochrane Library, Medline, PubMed, ScienceDirect, Web of Science, and TR index databases using the keywords "kangaroo care AND preterm AND vital signs." The pool mean differences (MDs) were calculated, adopting a 95% confidence interval (CIs) using the Stata 16 software for the meta-analysis [PROSPERO: CRD42021283475].

RESULTS

Eleven studies for systematic review and nine studies for meta-analysis, including 634 participants, were found eligible for inclusion. It was determined that the "temperature" (z = 3.21; p = 0.000) and "oxygen saturation" (z = 2.49; p = 0.000) values created a positive effect in general in the kangaroo care group; however, there was no sufficient evidence to state that it affected the "heart rate" (z = -0.60; p = 0.55) and "respiratory rate" (z = -1.45; p = 0.15) values. In the present study, the duration of KMC application had statistically different effects on temperature and oxygen saturation (SpO₂) (p < 0.05). One-hour or shorter applications of KMC had a higher effect on the temperature and oxygen saturation values (1.83; 1.62, respectively).

CONCLUSION

Our results provided references for clinical implications, and the "temperature" and "oxygen saturation (SpO₂)" values created a positive effect in general in the KMC group. However, there was no sufficient evidence to state that it affected the "heart rate" and "respiratory rate" values. The duration of KMC application had statistically different effects on temperature and oxygen saturation. One-hour or shorter applications of KMC had a higher effect on the temperature and SpO₂ values. Longitudinal, randomized, controlled studies examining the effects of KMC on vital signs in premature newborns with vital parameters outside the normal reference range are recommended.

PRACTICE IMPLICATIONS

The goal of the NICU nurse is to improve the infant's well-being. The application of KMC is a unique care for the nurse in maintaining the newborn's well-being. The vital signs of newborns hospitalized in the NICU with critical problems may be out of normal limits. KMC is an essential developmental care practice that ensures that the neonate's vital signs are kept within normal limits by relaxing the neonate, reducing stress, increasing comfort, and supporting interventions and treatments. KMC application is unique for each mother‑neonate pair. Depending on the tolerance of the mother and infant in terms of duration, it is recommended to perform KMC in the NICU under the supervision of a nurse. Neonatal nurses should support mothers in giving KMC in the NICU since KMC has ameliorative effects on the vital signs of premature neonates.

Early Skin-to-Skin Contact in Preterm Infants: Is It Safe? An Italian Experience

BACKGROUND

Skin-to-skin contact (SSC) is one of the four components of kangaroo care (KC) and is also a valued alternative to incubators in low-income countries. SSC has also become a standard of care in high-income countries because of its short- and long-term benefits and its positive effect on infant growth and neurodevelopmental outcome. However, barriers in the implementation of SSC, especially with preterm infants, are common in NICUs because parents and health care professionals can perceive it as potentially risky for the clinical stability of preterm infants. Previous studies have assessed safety before and during SSC by monitoring vital parameters during short-time intervals.

AIMS

To demonstrate the safety of early SSC in preterm infants during at least 90 min intervals.

DESIGN

Prospective observational monocentric study.

METHODS

Preterm infants born between June 2018 and June 2020 with a gestational age of ≤33 weeks and a birth weight of <2000 g were monitored while performing an SSC session during the first three weeks of life. Infants with necrotizing enterocolitis, sepsis, and congenital malformations on mechanical ventilation or with more than five apneas in the hour before SSC were excluded. Continuous oxygen saturation (SaO2), heart rate (HR), and respiratory rate (RR) were registered during an SSC session and in the hour before. The minimum duration of an SSC session was 90 min. Information regarding postmenstrual age (PMA), body weight, respiratory support, presence of a central venous catheter and the onset of sepsis within 72 h after a session was collected. Two physicians, blinded to infant conditions and the period of analysis (before or during SSC), evaluated desaturation episodes (SaO2 < 85%, >15 s), bradycardia (HR < 100, >15 s) and apneas (pause in breathing > 20 s associated with desaturation and/or bradycardia). A Wilcoxon rank sum test was used for the statistical analysis.

RESULTS

In total, 83 episodes of SSC were analyzed for a total of 38 infants. The mean gestational age at birth was 29 weeks (range 23-33 weeks). Median PMA, days of life, and body weight at SSC were 31 weeks (range 25-34 weeks), 10 days (range 1-20 days), and 1131 g (range 631-2206 g), respectively. We found that 77% of infants were on respiratory support and 47% of them had a central venous catheter (umbilical or peripherally inserted central catheter) during SSC. The total duration of desaturation, bradycardia, and the number of apneas were not statistically different during the SSC session and the hour before. No catheter dislocation or ruptures were reported.

CONCLUSIONS

These findings highlighted the safety of early SSC in preterm infants and the possibility of performing it in an intensive care setting in the first weeks of life. In addition, these findings should reassure health care professionals offering this practice as a standard of care. SSC plays a key role in the care of preterm infants due to its short- and long-term positive benefits, and it deserves to be increasingly offered to infants and their parents.

Early skin-to-skin contact and risk of late-onset-sepsis in very and extremely preterm infants

BACKGROUND

To evaluate the association between exposure to early skin-to-skin contact (SSC) and incidence of late-onset sepsis (LOS) in extremely and very preterm infants.

METHODS

Observational study using the national population-based EPIPAGE-2 cohort in 2011. A propensity score for SSC exposure was used to match infants with and without exposure to SSC before day 4 of life and binomial log regression used to estimate risk ratios and CIs in the matched cohort. The primary outcome was at least one episode of LOS during hospitalization. Secondary outcomes were the occurrence of any late-onset neonatal infection (LONI), LOS with Staphylococcus or Staphylococcus aureus, incidence of LOS and LONI per 1000 central venous catheter days.

RESULTS

Among the 3422 included infants, 919 were exposed to early SSC. The risk ratio (RR) for LOS was 0.86 (95% CI, 0.67-1.10), for LONI was 1.00 (95% CI, 0.83-1.21), and for LOS with Coagulase-negative Staphylococcus or Staphylococcus aureus infection was 0.91 (95% CI, 0.68-1.21) and 0.77 (95% CI, 0.31-1.87). The incidence RR for LOS per-catheter day was 0.87 (95% CI, 0.64-1.18).

CONCLUSION

Early SSC exposure was not associated with LOS or LONI risk. Thus, their prevention should not be a barrier to a wider use of SSC.

IMPACT

Kangaroo Mother Care decreased neonatal infection rates in middle-income countries. Skin-to-skin contact is beneficial for vulnerable preterm infants but barriers exist to its implementation. In a large population-based study using a propensity score methods, we found that skin-to-skin contact before day 4 of life was not associated with a decreased risk of late-onset-sepsis in very and extremely preterm infants. Early skin-to-skin contact was not associated with an increased risk of any late-onset-neonatal-infection, in particular with staphylococcus. The fear of neonatal infection should not be a barrier to a wider use of early skin-to-skin contact in this population.

Skin-to-skin SDF positioning: The key to intersubjective intimacy between mother and very preterm newborn-A pilot matched-pair case-control study

Background

Skin-to-skin contact (SSC) has been widely studied in NICU and several meta-analyses have looked at its benefits, for both the baby and the parent. However, very few studies have investigated SSC' benefits for communication, in particular in the very-preterm newborn immediately after birth.

Aims

To investigate the immediate benefits of Supported Diagonal Flexion (SDF) positioning during SSC on the quality of mother-very-preterm newborn communication and to examine the coordination of the timing of communicative behaviors, just a few days after birth.

Subjects and study design

Monocentric prospective matched-pair case-control study. Thirty-four mothers and their very preterm infants (27 to 31 + 6 weeks GA, mean age at birth: 30 weeks GA) were assigned to one of the two SSC positioning, either the Vertical Control positioning (n = 17) or the SDF Intervention positioning (n = 17). Mother and newborn were filmed during the first 5 min of their first SSC.

Outcome measures

Infants' states of consciousness according to the Assessment of Preterm Infants' Behavior scale (APIB). Onset and duration of newborns' and mothers' vocalizations and their temporal proximity within a 1-s time-window.

Results

In comparison with the Vertical group, very preterm newborns in the SDF Intervention Group spent less time in a drowsy state and more in deep sleep. At 3.5 days of life, newborns' vocal production in SSC did not differ significantly between the two groups. Mothers offered a denser vocal envelope in the SDF group than in the Vertical group and their vocalizations were on average significantly longer. Moreover, in a one-second time-frame, temporal proximity of mother-very preterm newborn behaviors was greater in the SDF Intervention Group.

Conclusion

Although conducted on a limited number of dyads, our study shows that SDF positioning fosters mother-very preterm newborn intimate encounter during the very first skin to skin contact after delivery. Our pioneer data sheds light on the way a mother and her very preterm vocally meet, and constitutes a pilot step in the exploration of innate intersubjectivity in the context of very preterm birth.

Mother and newborn skin-to-skin contact in sub-Saharan Africa: prevalence and predictors

Introduction

Skin-to-skin contact is an evidence-based intervention that signifies a situation whereby a newborn is positioned directly on the mother’s abdomen or chest in order for them to have direct ventral-to-ventral skin contact. The act of skin-to-skin contact begins immediately after delivery to about 23 hours afterwards. Evidence shows that skin-to-skin contact is important in improving child health outcomes. Nevertheless, evidence on its prevalence and predictors in sub-Saharan Africa (SSA) remains sparse. The study, therefore, estimated the prevalence of skin-to-skin contact between mothers and their newborns, as well as its predictors.

Methods

Using data from the recent Demographic and Health Survey conducted between 2015 and 2020 from 17 countries in SSA, we included 131 094 women who gave birth in the last 5 years preceding the survey in the final analysis. We used percentages to summarise the prevalence of skin-to-skin contact. Multilevel logistic regression analysis was used to determine the predictors of skin-to-skin contact. Adjusted odds ratios (ORs) with their corresponding 95% confidence intervals (CIs) were used to present the results of the regression analysis.

Results

Approximately 42% (41.7 to 42.2) of mothers practiced newborn skin-skin contact. The highest prevalence was found in Benin (75.1% (74.1 to 76.0)) and the lowest prevalence in Nigeria (11.7% (11.2 to 12.1)). The likelihood of skin-to-skin contact was higher among women covered by health insurance, those who delivered in health facilities, those in the richest wealth index, women who attended 1–3 antenatal care (ANC) visits and four or more ANC visits, and those with secondary or higher education. The odds of skin-to-skin contact was low among women who delivered by caesarean section (adjusted OR=0.15; 95% CI 0.13 to 0.16).

Conclusion

Considering that less than half of the surveyed women practiced skin-to-skin contact, it is expedient for intensification of advocacy and strict supervision of the practice within the included countries. Informal educational programmes can also be rolled out through various media platforms to sensitise the public and healthcare providers on the need for skin-to-skin contact. These will help maximise the full benefits of skin-to-skin contact and expedite prospects of achieving the Sustainable Development Goal targets 3.1 and 3.2.

Effects of early essential newborn care versus routine birth care on physiological variables and sleep state among newborn infants: a quasi-experimental design

BACKGROUND

Early essential newborn care (EENC) was introduced to medical practice in China in 2016, but the number of medical institutions that have put EENC into practice remains low due to insufficient clinical evidence and the absence of awareness among health professionals. This study aimed to explore the effect of EENC on physiological variables and sleep state among newborn infants and to provide evidence to support the implementation of EENC.

METHODS

A quasi-experimental design was conducted among 182 newborn infants in a tertiary maternity hospital in China from May 2020 to January 2021. A total of 91 newborn infants were included in the intervention group, and 91 were included in the control group to receive EENC or routine birth care, respectively.

RESULTS

The newborn infants in the intervention group had a lower incidence of hypothermia than those in the control group at 75 min, 90 min, 105 min, and 120 min after birth (p < 0.05). The time of first breathing after birth in the intervention group was earlier than that in the control group (5 s vs. 7 s, p < 0.05), and the infants had a better sleep state at 30 min, 60 min, 90 min, and 120 min after birth (p < 0.05).

CONCLUSIONS

EENC can decrease the incidence of hypothermia, promote the initiation of breathing, and improve the sleep state among newborn infants compared to routine birth care in China. More coaching should be provided to health professionals to promote the implementation of EENC in China.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, Retrospective Registration (27/7/2021), registration number: ChiCTR2100049231 .

Diffusion Tensor Imaging Changes Do Not Affect Long-Term Neurodevelopment following Early Erythropoietin among Extremely Preterm Infants in the Preterm Erythropoietin Neuroprotection Trial

We aimed to evaluate diffusion tensor imaging (DTI) in infants born extremely preterm, to determine the effect of erythropoietin (Epo) on DTI, and to correlate DTI with neurodevelopmental outcomes at 2 years of age for infants in the Preterm Erythropoietin Neuroprotection (PENUT) Trial. Infants who underwent MRI with DTI at 36 weeks postmenstrual age were included. Neurodevelopmental outcomes were evaluated by Bayley Scales of Infant and Toddler Development (BSID-III). Generalized linear models were used to assess the association between DTI parameters and treatment group, and then with neurodevelopmental outcomes. A total of 101 placebo- and 93 Epo-treated infants underwent MRI. DTI white matter mean diffusivity (MD) was lower in placebo- compared to Epo-treated infants in the cingulate and occipital regions, and occipital white matter fractional isotropy (FA) was lower in infants born at 24-25 weeks vs. 26-27 weeks. These values were not associated with lower BSID-III scores. Certain decreases in clustering coefficients tended to have lower BSID-III scores. Consistent with the PENUT Trial findings, there was no effect on long-term neurodevelopment in Epo-treated infants even in the presence of microstructural changes identified by DTI.

Combining Kangaroo Care and Live-Performed Music Therapy: Effects on Physiological Stability and Neurological Functioning in Extremely and Very Preterm Infants

Interventions such as kangaroo care (KC) and live-performed music therapy (LPMT), are increasingly used to facilitate stress reduction in neonates. This study aims to investigate the effect of combining the two on physiological responses and neurological functioning in very preterm infants. Infants received six sessions of LPMT. KC was added to one LPMT session. Physiological responses included heart rate, respiratory rate and oxygen saturation. We videotaped infants for 30 min before and after two sessions to assess general movements (GMs). We included 17 infants, gestational age median 26.0 weeks (IQR 25.6–30.6 weeks), of whom six were males. Combined interventions showed a decrease in heart rate from mean 164 bpm before to 157 bpm during therapy, p = 0.001. Oxygen saturation levels increased during combination therapy from median 91.4% to 94.5%, p = 0.044. We found no effects of LPMT or combined interventions on GMs. Infants with a postnatal age (PNA) <7 days generally seem to display less optimal GMs after therapy compared with infants with a PNA >7 days. In conclusion, combining interventions is equally beneficial for physiological stability and neurological functioning as LPMT alone. Future studies should focus on the effects of this combination on parent-infant bonding.

Fathers' oxytocin responses to first holding their newborns: Interactions with testosterone reactivity to predict later parenting behavior and father-infant bonds

Little is known about human fathers' physiology near infants' births. This may represent a period during which paternal psychobiological axes are sensitive to fathers' new experiences of interacting with their newborns and that can provide insights on how individual differences in fathers' biology relate to post-partum parenting. Drawing on a sample of men in South Bend, IN (U.S.), we report results from a longitudinal study of fathers' oxytocin, cortisol, and testosterone (N = 211) responses to their first holding of their infants on the day of birth and men's reported caregiving and father-infant bonding at 2-4 months post-partum (N = 114). First-time fathers' oxytocin was higher following first holding of their newborns, compared to their pre-holding levels. Contrasting with prior results, fathers' percentage change in oxytocin did not differ based on skin-to-skin or standard holding. Drawing on psychobiological frameworks, we modeled the interactions for oxytocin reactivity with testosterone and cortisol reactivity, respectively, in predicting father-infant outcomes months later. We found significant cross-over interactions for (oxytocin × testosterone) in predicting fathers' later post-partum involvement and bonding. Specifically, we found that fathers whose testosterone declined during holding reported greater post-partum play if their oxytocin increased, compared to fathers who experienced increases in both hormones. We also observed a similar non-significant interaction for (oxytocin × cortisol) in predicting fathers' post-partum play. Fathers whose testosterone declined during holding also reported less involvement in direct caregiving and lower father-infant bonding if their oxytocin decreased but greater direct care and bonding if their testosterone increased and oxytocin decreased. The results inform our understanding of the developmental time course of men's physiological responsiveness to father-infant interaction and its relevance to later fathering behavior and family relationships.

Kangaroo mother care alters chromogranin A and perfusion index in preterm babies

BACKGROUND

While providing various benefits, concerns about the potential risks of kangaroo mother care, or skin-to-skin contact (SSC), between mother and her preterm infant hinder its widespread implementation in some resource- rich countries. In neonates, salivary chromogranin A (s-CgA) is elevated upon exposure to stress, whereas the perfusion index (PI) is associated with hemodynamics and peripheral perfusion. Here, we investigated the effects of SSC on s-CgA and the PI in preterm infants.

METHODS

Twelve infants were enrolled in the study. Factors associated with baseline s-CgA were analyzed. Baseline s-CgA and the level after SSC were compared. Secreted IgA in the saliva was compared as the control. The PI before, throughout, and after SSC were compared.

RESULTS

Baseline s-CgA was significantly lower in infants who were supplemented with baby formula milk in addition to breast milk before SSC (n = 2) compared with those fed with their mother's breast milk alone (n = 10, P = 0.03). SSC significantly decreased s-CgA in babies who were fed breast milk only before SSC (n = 10, P = 0.01) but not in those supplemented with formula milk before SSC (n = 2). Secreted IgA in saliva was not affected by SSC. The PI was significantly elevated during SSC (P = .01).

CONCLUSION

Our data indicate that SSC can reduce s-CgA levels when combined with mother's breast milk and increase the PI in preterm infants, thereby providing additional evidence of the benefit of SSC.

Fostering mother-very preterm infant communication during skin-to-skin contact through a modified positioning

BACKGROUND

Skin-to-skin contact (SSC) has been widely studied in NICU and several meta-analyses have looked at its benefits both for the baby and the parent. Very few studies however have investigated benefit for communication.

AIMS

Investigate the immediate benefits of Supported Diagonal Flexion (SDF) positioning during SSC on the quality of mother - very-preterm infant communication and to gain insight into how mothers' and very-preterm infants' communicative behaviours are coordinated in time just a few days after birth.

SUBJECTS AND STUDY DESIGN

Monocentric prospective matched-pair case-control study. Thirty-four mothers and their very preterm infants (27 to 31 + 6 weeks GA; mean age at birth 30: weeks GA) were assigned to one of the two SSC positioning, either the Vertical Control (n = 17) or the SDF Intervention positioning (n = 17). Mother and infant were filmed during the first 5 min of SSC, 15 days after the very first SSC (i.e. 18 days after very premature birth, i.e. on average 32.4 weeks GA).

OUTCOME MEASURES

Infants' state of consciousness according to the Assessment of Preterm Infants' Behavior scale. Onset and duration of infants' and mothers' smiles, gazes and vocalizations, and their temporal proximity inside a 1-sec time-window.

RESULTS

In the SDF Intervention Group, very preterm infants vocalized three times more and mothers vocalized, gazed at their baby's face, and smiled more than in the Vertical Control Group. Moreover, in a one-second time-frame, temporal proximity of mother-infant behaviours was greater in the SDF Intervention Group.

CONCLUSIONS

Our study shows that SDF positioning creates more opportunities for mother-infant communication during SSC. SDF positioning fosters a greater multimodal temporal proximity thus supporting a more qualitative mother-infant communication.

The effect of mother-infant skin-to-skin contact on Ghanaian infants' response to the Still Face Task: Comparison between Ghanaian and Canadian mother-infant dyads

The effect of mother-infant skin-to-skin contact on Ghanaian infants' developing social expectations for maternal behavior was investigated. Infants with high and low mother-infant skin-to-skin contact experience in the infants' first month engaged with their mothers in a Still Face Task at 6 weeks of age. Infants with high skin-to-skin contact experience, but not those with low skin-to-skin contact experience, demonstrated the still face effect with their smiles. Infants with both high and low skin-to-skin contact experience demonstrated the still face effect with their visual attention. The behaviors of the Ghanaian infants and their mothers during the task were compared to archival evidence of Canadian mother-infant dyads' behaviors in skin-to-skin and control groups who engaged in the Still Face Task at the infant ages of 1 and 2 months. Similarities and differences between the behaviors of the mother-infant dyads in the two cultures were assessed.

Parent Engagement Correlates With Parent and Preterm Infant Oxytocin Release During Skin-to-Skin Contact

BACKGROUND

Preterm infants remain increasingly neurodevelopmentally disadvantaged. Parental touch, especially during skin-to-skin contact (SSC), has potential to reduce adverse consequences.

PURPOSE

To examine relationships between parental engagement and salivary oxytocin and cortisol levels for parents participating in SSC intervention.

METHODS

A randomized crossover design study was conducted in a neonatal intensive care unit; 28 stable preterm infants, mothers, and fathers participated. Parental engagement was measured using the Parental Risk Evaluation Engagement Model Instrument (PREEMI) prior to hospital discharge. Saliva samples for oxytocin and cortisol levels were collected 15-minute pre-SSC, 60-minute during-SSC, and 45-minute post-SSC.

RESULTS

Data were analyzed using Pearson's correlation to measure relationships between parental engagement composite scores and salivary oxytocin and cortisol levels. A significant negative correlation between paternal engagement and paternal oxytocin levels (r = -0.43; P = .03) and a significant negative correlation between infant oxytocin levels and maternal engagement (r = -0.54; P = .004) were present. Adjusted linear regression models demonstrated that as infant oxytocin levels increased during SSC, maternal engagement scores significantly decreased at discharge (β = -.04; P = .01). Linear regression, adjusting for infant oxytocin and cortisol levels, showed that as paternal oxytocin levels increased, there was a significant decrease in paternal engagement (β = -.16; P = .03) and as paternal cortisol levels increased, there was a significant decrease in paternal engagement (β = -68.97; P =.05).

IMPLICATIONS FOR PRACTICE

Significant relationships exist between parental engagement and salivary oxytocin and cortisol levels. Defining parent engagement facilitates identification of parent risks and needs for intervention to optimize preterm outcomes.

IMPLICATIONS FOR RESEARCH

The PREEMI can serve as a standardized instrument to examine parent engagement.

Neonatal intestinal injury induced by maternal separation: pathogenesis and pharmacological targets 1

Maternal separation (MS) is a well-studied phenomenon thought to play a role in the pathogenesis of many diseases ranging from neuropsychiatric to early intestinal disorders such as necrotizing enterocolitis. The existing evidence suggests that MS initiates a variety of processes that in turn lead to early intestinal injury. Although there are many theories as to how MS alters normal physiological processes, the exact mechanism of action remains to be elucidated. This review aims to describe some of the pathological processes affecting the intestine that are caused by MS, including (i) brain-gut axis, (ii) intestinal epithelial barrier function, (iii) microbiome, (iv) oxidative stress and endoplasmic reticulum stress, and (v) gut inflammation.

Regular and prolonged skin-to-skin contact improves short-term outcomes for very preterm infants: A dose-dependent intervention

INTRODUCTION

Skin-to-skin contact (SSC) is a cornerstone of neurodevelopment and family-oriented care for preterm infants. The purpose of the present study was to investigate the effectiveness of skin-to-skin contact in preterm babies depending on regularity, duration, and the period of the first contact.

MATERIALS AND METHODS

This retrospective study involved 26 premature infants with gestational age 24/0-28/6 weeks who were treated in the neonatal intensive care unit and neonatal department. All infants had SSC with their parents.

RESULTS

According to the first SSC, newborns were divided into two groups: group 1 (SSC began in the 1st week of life) and group 2 (SSC began after the 1st week of life). Group A (SSC was performed regularly, i.e., everyday) and group B (SSC was irregular, i.r., once every 2 or 3 days) were based on the regularity of SSC. Depending on the duration of SSC, group І (SSC was more than 3h per day) and group II (SSC was less than 3h per day) were formed. Early SSC correlated with lower incidence of secondary infections (OR=6.75; 95% CI 1.06-42.84; P=0.051), bronchopulmonary dysplasia (OR=10.67; 95% CI 1.70-66.72; P<0.015), and cholestasis (P=0.022). Regular SSC correlated with lower incidence of secondary infections (OR=15.0; 95% CI 1.50-149.70; P=0.014). Duration of SSC was correlated with lower rates of secondary infections (OR=7.00; 95% CI 1.20-40.83; P=0.043) and better rates of breastfeeding (OR=7.00; 95% CI 1.20-40.83; P=0.043).

CONCLUSION

Early, regular, and prolonged SSC has a positive impact on premature infants' health. In particular, early SSC is associated with a reduced risk of BPD development, cholestasis, and nosocomial infection. Prolonged daily skin-to-skin contact is associated with a lower incidence of nosocomial infection and promotes breastfeeding.

Social touch during development: Long-term effects on brain and behavior

In this paper, our goal is to explore what is known about the role of social touch during development. We first address the neural substrates of social touch and the role of tactile experience in neural development. We discuss natural variation in early exposure to social touch, followed by a discussion on experimental manipulations of social touch during development and "natural experiments", such as early institutionalization. We then consider the role of other developmental and experiential variables that predict social touch in adults. Throughout, we propose and consider new theoretical models of the role of social touch during development on later behavior and neurobiology.

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.

Programming of the Adult HPA Axis After Neonatal Separation and Environmental Stress in Male and Female Rats

Maternal separation, hypoxia, and hypothermia are common stressors in the premature neonate. Using our rat model of human prematurity, we evaluated sexual dimorphisms in the long-term effects of these neonatal stressors on behavior of the hypothalamic-pituitary-adrenal (HPA) axis in adult rats. Neonatal rats were exposed daily on postnatal days 2 to 6 to maternal separation with normoxia, with hypoxia allowing spontaneous hypothermia, with hypothermia per se, and with hypoxia while maintaining isothermia with external heat. The major findings were that (a) prior maternal-neonatal separation during the first week of postnatal life attenuated the plasma ACTH and corticosterone response to restraint stress in adult male but not female rats, (b) prior neonatal hypothermia augmented the plasma ACTH and corticosterone response to restraint stress in adult male rats, but not female rats, and (c) changes in hypothalamic, pituitary, and adrenal mRNA expression did not account for most of these HPA axis effects. Most of the programming effects on adult HPA axis was attributed to prior maternal-neonatal separation alone (with normoxia) because the addition of hypoxia with spontaneous hypothermia, hypothermia per se, and hypoxia while preventing hypothermia during maternal-neonatal separation had minimal effects on the HPA axis. These results may inform strategies to prevent sexually dimorphic sequelae of neonatal stress including those due to medical interventions.

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

Objective:

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

Methods:

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

Results:

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

Conclusion:

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

Insulin sensitivity, leptin, adiponectin, resistin, and testosterone in adult male and female rats after maternal-neonatal separation and environmental stress

Care of premature infants often requires parental and caregiver separation, particularly during hypoxic and hypothermic episodes. We have established a neonatal rat model of human prematurity involving maternal-neonatal separation and hypoxia with spontaneous hypothermia prevented by external heat. Adults previously exposed to these neonatal stressors show a sex difference in the insulin and glucose response to arginine stimulation suggesting a state of insulin resistance. The current study used this cohort of adult rats to evaluate insulin resistance [homeostatic model assessment of insulin resistance (HOMA-IR)], plasma adipokines (reflecting insulin resistance states), and testosterone. The major findings were that daily maternal-neonatal separation led to an increase in body weight and HOMA-IR in adult male and female rats and increased plasma leptin in adult male rats only; neither prior neonatal hypoxia (without or with body temperature control) nor neonatal hypothermia altered subsequent adult HOMA-IR or plasma adiponectin. Adult male-female differences in plasma leptin were lost with prior exposure to neonatal hypoxia or hypothermia; male-female differences in resistin were lost in the adults that were exposed to hypoxia and spontaneous hypothermia as neonates. Exposure of neonates to daily hypoxia without spontaneous hypothermia led to a decrease in plasma testosterone in adult male rats. We conclude that neonatal stressors result in subsequent adult sex-dependent increases in insulin resistance and adipokines and that our rat model of prematurity with hypoxia without hypothermia alters adult testosterone dynamics.

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 Effects of Kangaroo Care in the Neonatal Intensive Care Unit on the Physiological Functions of Preterm Infants, Maternal-Infant Attachment, and Maternal Stress

This study was conducted to identify the effects of kangaroo care on the physiological functions of preterm infants, maternal-infant attachment, and maternal stress.

DESIGN AND METHODS

For this study, a quasi-experiment design was used with a nonequivalent control group, and a pre- and post-test. Data were collected from preterm infants with corrected gestational ages of ≥33weeks who were hospitalized between May and October 2011. Twenty infants were assigned to the experimental group and 20 to the control group. As an intervention, kangaroo care was provided in 30-min sessions conducted thrice a week for a total of 10 times. The collected data were analyzed by using the t test, repeated-measures ANOVA, and the ANCOVA test.

RESULTS

After kangaroo care, the respiration rate significantly differed between the two groups (F=5.701, p=.020). The experimental group had higher maternal-infant attachment scores (F=25.881, p<.001) and lower maternal stress scores (F=47.320, p<.001) than the control group after the test. In other words, kangaroo care showed significantly positive effects on stabilizing infant physiological functions such as respiration rate, increasing maternal-infant attachment, and reducing maternal stress.

CONCLUSION

This study suggests that kangaroo care can be used to promote emotional bonding and support between mothers and their babies, and to stabilize the physiological functions of premature babies.

PRACTICE IMPLICATIONS

Kangaroo care may be one of the most effective nursing interventions in the neonatal intensive care unit for the care of preterm infants and their mothers.

Educational Intervention for an Evidence-Based Nursing Practice of Skin-to-Skin Contact at Birth

This article presents the development and evaluation of an educational intervention aiming at an evidence-based practice of skin-to-skin contact at birth among nurses of a maternity care unit. Based on the Iowa Model of Evidence-Based Practice to Promote Quality Care, four educational sessions were developed according to an active-learning pedagogy. Even if the nurses' practice did not fully meet the recommendations for skin-to-skin contact, a pre- and postintervention evaluation showed some positive results, such as a longer duration of skin-to-skin contact immediately after birth, delivery of some routine care directly on mothers' chest, and improved parent education. The educational intervention seems to have enacted some evidence-based nursing practice changes regarding skin-to-skin contact at birth.

A Case Study of Infant Physiologic Response to Skin-to-Skin Contact After Surgery for Complex Congenital Heart Disease

BACKGROUND

Infants with complex congenital heart disease requiring surgical intervention within the first days or weeks of life may be the most seriously ill infants needing intensive nursing and medical care. Skin-to-skin contact (SSC) is well accepted and practiced as a positive therapeutic intervention in premature infants but is not routinely offered to infants in cardiac intensive care units. The physiologic effects of SSC in the congenital heart disease population must be examined before recommending incorporation of SSC into standard care routines.

OBJECTIVE

The purpose of this case study was to describe the physiologic response to a single session of SSC in an 18-day-old infant with hypoplastic left heart syndrome.

METHODS

Repeated measures of heart rate, respiratory rate, oxygen saturation, blood pressure, and temperature were recorded 30 minutes before SSC, during SSC (including interruptions for bottle and breast feedings), and 10 minutes after SSC was completed.

RESULTS

All physiologic parameters were clinically acceptable throughout the 135-minute observation.

CONCLUSION

This case study provides beginning evidence that SSC is safe in full-term infants after surgery for complex congenital heart disease. Further research with a larger sample is needed to examine the effects of SSC on infant physiology before surgery and earlier in the postoperative time period as well as on additional outcomes such as length of stay, maternal-infant interaction, and neurodevelopment.

Skin-to-Skin Care for Term and Preterm Infants in the Neonatal ICU

“Kangaroo mother care” was first described as an alternative method of caring for low birth weight infants in resource-limited countries, where neonatal mortality and infection rates are high because of overcrowded nurseries, inadequate staffing, and lack of equipment. Intermittent skin-to-skin care (SSC), a modified version of kangaroo mother care, is now being offered in resource-rich countries to infants needing neonatal intensive care, including those who require ventilator support or are extremely premature. SSC significantly improves milk production by the mother and is associated with a longer duration of breastfeeding. Increased parent satisfaction, better sleep organization, a longer duration of quiet sleep, and decreased pain perception during procedures have also been reported in association with SSC. Despite apparent physiologic stability during SSC, it is prudent that infants in the NICU have continuous cardiovascular monitoring and that care be taken to verify correct head positioning for airway patency as well as the stability of the endotracheal tube, arterial and venous access devices, and other life support equipment.

A theory of social thermoregulation in human primates

Beyond breathing, the regulation of body temperature-thermoregulation-is one of the most pressing concerns for many animals. A dysregulated body temperature has dire consequences for survival and development. Despite the high frequency of social thermoregulation occurring across many species, little is known about the role of social thermoregulation in human (social) psychological functioning. We outline a theory of social thermoregulation and reconsider earlier research on people's expectations of their social world (i.e., attachment) and their prediction of the social world. We provide support and outline a research agenda that includes consequences for individual variation in self-regulatory strategies and capabilities. In our paper, we discuss physiological, neural, and social processes surrounding thermoregulation. Emphasizing social thermoregulation in particular, we appeal to the economy of action principle and the hierarchical organization of human thermoregulatory systems. We close with future directions of a crucial aspect of human functioning: the social regulation of body temperature.

Effect of maternal skin-to-skin contact on decolonization of Methicillin-Oxacillin-Resistant Staphylococcus in neonatal intensive care units: a randomized controlled trial

Background

Decolonization with topical antibiotics is necessary to control outbreaks of multidrug-resistant bacterial infection in the Neonatal Intensive Care Unit (NICU), but can trigger bacterial resistance. The objective of this study was to determine whether skin-to-skin contact of newborns colonized with Methicillin-Oxacillin Resistant Staphylococcus aureus or Methicillin-Oxacillin-Resistant Coagulase-Negative Staphylococcus aureus (MRSA/MRSE) with their mothers could be an effective alternative to promote bacterial decolonization of newborns’ nostrils.

Methods

We performed a randomized clinical trial with 102 newborns admitted to the NICU in three hospitals in São Luís, Brazil. Inclusion criteria were birth weight of 1300 to 1800 g, more than 4 days of hospitalization, newborns with positive nostril cultures for MRSA and/or multidrug-resistant coagulase-negative Staphylococcus and mothers not colonized by these bacteria. We used a random number algorithm for randomization. Allocation was performed using sealed opaque envelopes. Skin-to-skin contact was given twice a day for 60 minutes for seven consecutive days. The control group received routine care without skin-to-skin contact. There was no masking of newborn’s mothers or researchers but the individuals who carried out bacterial cultures and assessed results were kept blind to group allocation. The primary outcome was colonization status of newborns’ nostrils after 7 days of intervention. The directional hypothesis was that more newborns who receive skin-to-skin holding 2 hours/day for 7 days than newborns who receive normal care will be decolonized.

Results

Decolonization of MRSA/MRSE was greater in the intervention group (Risk Ratio = 2.27; 95% CI 1.27-4.07, p-value = 0.003). Number Needed to Treat (NNT) was 4.0 (95% CI 2.2 – 9.4). After adjustment for the possible confounding effects of small for gestational age birth, antibiotic use, need for resuscitation, sex and cesarean delivery, skin-to-skin contact remained strongly associated with decolonization of newborns’ nostrils from MRSA/MRSE bacteria (p = 0.007). There was no need to interrupt the trial for safety reasons.

Conclusion

Skin-to-skin contact might be an effective and safe method for promoting decolonization of newborns’ nostrils colonized by MRSA/MRSE.

Trial Registration

The study was registered with ClinicalTrials.gov (NCT01498133, November 21, 2011).

Kangaroo care: cardio-respiratory relationships between the infant and caregiver

BACKGROUND

Kangaroo care, i.e., skin-to-skin cohabitation (SSC) between an infant and caregiver, is often used in neonatal intensive care units to promote bonding, breastfeeding and infant growth. The direct salutary effects of SSC on cardio-respiratory control in preterm infants remain equivocal; some reports suggest improved breathing stability, others indicate worsening of apnea, bradycardia and hypoxemia.

AIM

The purpose of this study was to investigate physiological relationships between the infant and caregiver during SSC. We hypothesized that respiratory stability of the premature infant is influenced by the caregiver's heartbeat.

DESIGN

A prospective study was performed in eleven preterm infants (6 female; mean PCA 32 wks). SSC was compared to a preceding incubator-control period (CTL) matched for time from feed and condition duration. Abdominal respiratory movement, electrocardiogram, skin temperature and blood-oxygen levels were recorded from the infant and the caregiver.

RESULTS

During CTL, infant interbreath interval variance (IBIv; respiratory instability) was directly related to its own heart rate variance (HRv; rho=0.770, p=0.009). During SSC, infant IBIv and apnea incidence were each related to caregiver HRv (rho 0.764, p=0.006; rho 0.677, p=0.022, respectively). Infant cardio-respiratory coupling was also enhanced during SSC compared to CTL in the eupneic frequency range (0.7-1.5 Hz, p=0.018) and reduced for slower frequencies (0.15-0.45 Hz; p=0.036).

CONCLUSION

These findings suggest that during SSC, respiratory control of the premature infant is influenced by the caregiver's cardiac rhythm. We propose that the caregiver's heartbeat causes sensory perturbations of the infant via somatic or other afferents, revealing a novel cohabitation-induced feed-back mechanism of respiratory control in the neonate.

Effect of kangaroo mother care on vital physiological parameters of the low birth weight newborn

Objectives:

Low birth weight (LBW; <2500 g), which is often associated with preterm birth, is a common problem in India. Both are recognized risk factors for neonatal mortality. Kangaroo mother care (KMC) is a non-conventional, low-cost method for newborn care based upon intimate skin-to-skin contact between mother and baby. Our objective was to assess physiological state of LBW babies before and after KMC in a teaching hospital setting.

Materials and Methods:

Study cohort comprised in-born LBW babies and their mothers - 300 mother-baby pairs were selected through purposive sampling. Initially, KMC was started for 1 hour duration (at a stretch) on first day and then increased by 1 hour each day for next 2 days. Axillary temperature, respiration rate (RR/ min), heart rate (HR/ min), and oxygen saturation (SpO₂) were assessed for 3 consecutive days, immediately before and after KMC.

Results:

Data from 265 mother-baby pairs were analyzed. Improvements occurred in all 4 recorded physiological parameters during the KMC sessions. Mean temperature rose by about 0.4°C, RR by 3 per minute, HR by 5 bpm, and SpO₂ by 5% following KMC sessions. Although modest, these changes were statistically significant on all 3 days. Individual abnormalities (e.g. hypothermia, bradycardia, tachycardia, low SpO₂) were often corrected during the KMC sessions.

Conclusions:

Babies receiving KMC showed modest but statistically significant improvement in vital physiological parameters on all 3 days. Thus, without using special equipment, the KMC strategy can offer improved care to LBW babies. These findings support wider implementation of this strategy.

Electromyographic activity of preterm newborns in the kangaroo position: a cohort study

OBJECTIVE

To compare the electromyographic activity of preterm newborns placed in the kangaroo position with the activity of newborns not placed in this position.

DESIGN

A cohort study.

SETTING

A Kangaroo Unit sector and a Nursery sector in a secondary and tertiary care at a mother-child hospital in Recife, Brazil.

PARTICIPANTS

Preterm infants of gestational age 27-34 weeks (n=38) and term infants (n=39).

PRIMARY AND SECONDARY OUTCOME MEASURES

Surface electromyography was used to investigate muscle activity in the brachial biceps at rest. 3 groups were designed: (1) preterm newborns in the kangaroo position (PT-KAN), where the newborn remains in a vertical position, lying face down, with limbs flexed, dressed in light clothes, maintaining skin-to-skin contact with the adult's thorax. Her electromyographic activity was recorded at 0 h (immediately before starting this position), and then at 48 h after the beginning of the position (but newborns were kept in the kangaroo position for 8-12 h per day) and at term equivalent age (40±1 weeks); (2) preterm newborns not in the kangaroo position (PT-NKAN), in which measurements were made at 0 h and 48 h; and (3) term newborns (T), in which measurements were made at 24 h of chronological age.

RESULTS

The Root Mean Square (RMS) values showed significant differences among groups (F(5,108)=56.69; p<0.001). The multiple comparisons showed that RMS was greater at 48 h compared to 0 h in the preterm group in the kangaroo position, but not in the group not submitted in the kangaroo position. The RMS in the term equivalent aged group in the kangaroo position was also greater when compared with those in the term group.

CONCLUSIONS

The kangaroo position increases electromyographic activity in the brachial biceps of preterm newborns and those who have reached the age equivalent to term.

The effect of kangaroo mother care on mental health of mothers with low birth weight infants

BACKGROUND

The mothers of premature infants are at risk of psychological stress because of separation from their infants. One of the methods influencing the maternal mental health in the postpartum period is kangaroo mother care (KMC). This study was conducted to evaluate the effect of KMC of low birth weight infants on their maternal mental health.

MATERIALS AND METHODS

The study was conducted in the Department of Pediatrics of Isfahan University of Medical Sciences, Isfahan, Iran. Premature infants were randomly allocated into two groups. The control group received standard caring in the incubator. In the experimental group, caring with three sessions of 60 min KMC daily for 1 week was practiced. Mental health scores of the mothers were evaluated by using the 28-item General Health Questionnaire. Statistical analysis was performed by the analysis of covariance using SPSS.

RESULTS

The scores of 50 infant-mother pairs were analyzed totally (25 in KMC group and 25 in standard care group). Results of covariance analysis showed the positive effects of KMC on the rate of maternal mental health scores. There were statistically significant differences between the mean scores of the experimental group and control subjects in the posttest period (P < 0.001).

CONCLUSION

KMC for low birth weight infants is a safe way to improve maternal mental health. Therefore, it is suggested as a useful method that can be recommended for improving the mental health of mothers.

Effect of early skin-to-skin contact following normal delivery on incidence of hypothermia in neonates more than 1800 g: randomized control trial

OBJECTIVE

To investigate the impact of early skin-to-skin contact (SSC) provided for first 24 h on incidence of hypothermia in stable newborns weighing 1800 g or more during first 48 h of life.

STUDY DESIGN

Stable newborns (term and late preterm: Mean gestational age 37.7 (1.35) weeks, range 34-40 weeks) having birth weight 1800 g or more (Mean weight 2605.6 (419.8) grams) were enrolled after approval from Institutional Human Research Ethics Committee (CTRI/2013/06/003790) and randomized into early SSC (intervention group) and conventional care (control group). Initial care in the delivery room for few minutes immediately after birth in both the groups was given under radiant warmer. In the intervention group, newborns were provided SSC by their mother started between 30 min and 1 h after birth for first 24 h with minimal interruption and were provided conventional care other than SSC for next 24 h of life. In the control group, newborns were kept with their mother and received conventional care other than SSC for first 48 h. Temperature and heart rate of newborns were recorded at 30 min, 1, 2, 3, 4, 5, 6, 12, 24 and at 48 h of life in both the groups. Independent Samples t-Test and relative risk were used to analyze the data.

RESULT

Both groups had 50 neonates each with similar baseline characteristics. Heart rates were in normal range in both the groups. The intervention group provided an average (s.d.) of 16.98 (0.28) h of SSC over the first 24 h period. The mean temperature was significantly high in the SSC group at all time intervals starting from 1 to 48 h (P<0.05 for all). In the SSC group only two newborns (4%) had mild hypothermia (cold stress), and, of these two newborns, one had two episodes of hypothermia. All these three episodes of hypothermia occurred within first 3 h of life. In the control group 16 newborns (32%) developed hypothermia (temperature<36.5 °C) during first 48 h of life. Of them, 11 newborns had single episode, 4 newborns had two episodes and one newborn had three episodes of hypothermia. Of these 22 hypothermic episodes, 20 occurred in the first 6 h of life and 2 episodes occurred at 48 h of life. Moderate hypothermia was seen in two newborns, whereas rest had mild hypothermia. The relative risk of developing hypothermia in the control group as compared with the SSC group was 8.00 (95% CI 1.94-32.99). There was no seasonal variation in incidence of hypothermia in both the groups.

CONCLUSION

Newborns in the SSC group achieved rapid thermal control as compared with the control group. Early SSC for 24 h after birth decreases incidence of hypothermia for initial 48 h of life. Early SSC needs to be aggressively promoted in term and late-preterm newborns to reduce incidence of hypothermia.

Practical application of kangaroo mother care in preterm infants: clinical characteristics and safety of kangaroo mother care

AIM

To determine the clinical characteristics and safety of kangaroo mother care (KMC) according to the gestational age (GA) or postmenstrual age (PMA).

METHODS

We conducted a prospective clinical study in 31 infants between 25 and 32 weeks' GA. The subjects were categorized into two groups (25-28 weeks' and 29-32 weeks' GA groups) to compare the clinical characteristics associated with KMC. Heart rate, respiratory rate, oxygen saturation, blood pressure and body temperature (BT) were longitudinally assessed for 60 min with respect to the PMA group (29-32 weeks' and 33-36 weeks' PMA groups).

RESULTS

The authors analyzed 70 sessions with 31 infants (25-32 weeks' GA, birth weight 760-1740 g, 29-36 weeks' PMA). All infants had statistically significant higher temperatures during KMC than before KMC within clinically acceptable limits (P<0.001). We found a significantly lower variation of BT in the 25-28 weeks' GA group compared with the 29-32 weeks' GA group at 33-36 weeks' PMA, suggesting accelerated skin maturation in more premature infants (P<0.001).

CONCLUSION

Our intermittent KMC was a safe and feasible method for preterm infants. Notably, at the same PMA, preterm infants in the lower at-birth GA group showed an advanced maturation of thermoregulation compared with those in the higher GA group.

Birth, bath, and beyond: the science and safety of water immersion during labor and birth

The 2014 objection to birth in water voiced by both the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (ACOG) in ACOG Bulletin #594 on immersion in water during labor and birth is nothing new. The Committee on Fetus and Newborn published the very same opinion in 2005, based on a case report that was published in 2002 in the journal Pediatrics. What has changed since 2002 is a growing body of evidence that reports on the safety and efficacy of labor and birth in water. This article reviews the retrospective literature on water birth and explains newborn physiology and the protective mechanisms that prevent babies from breathing during a birth in water.

Neonatal physiological and behavioral stress during neurological assessment

Physiological and behavioral effects of evaluative handling procedures were studied in 72 newborn infants: 36 preterm (30-35 weeks of gestation) and 36 full-term neonates (39-41 weeks of gestation). While the neurological assessment was physiologically and behaviorally destabilizing to both age groups, preterm subjects had higher heart rate (P < .001), greater increase in blood pressure (P < .01); decreased peripheral oxygenation inferred from mottled skin color (P < .001); and higher frequencies of finger splay (P < .001), arm salute (P < .01), hiccoughs (P < .001), and yawns (P < .001) than full-term subjects. Both groups demonstrated greater stress during the neuromotor phase of testing. Neonatal care professionals must scrutinize the diagnostic benefit, reliability, safety, and timing of neurological assessment given expected physiological and behavioral changes in stable preterm neonates.

Early sudden unexpected death in infancy (ESUDI)--three case reports and review of the literature

AIM

Early sudden unexpected death in infancy (ESUDI) is a rare cause of death occurring in newborns during the first hours of life. Our aim was to find additional data for the identification of risk factors and establishment of prevention strategies.

METHODS

We describe three cases of ESUDI and give an overview of the literature.

RESULTS

ESUDI was observed in term babies with normal birth weight after good postnatal adaptation within the first four hours of life. Maternal age was between 29 and 36 years, mothers were primiparous and of normal weight. All three events occurred during unobserved early skin-to-skin contact. Autopsy and post-mortem metabolic screening revealed no cause of death. A search of the MEDLINE and Web of Science (Thomson Reuters) databases brought to light 132 cases of ESUDI reported in the literature from 1985 to 2012. Concurrent with our observations, first parity and unobserved early skin-to-skin contact seem to be prime predictors of ESUDI. Other pre-described risk factors such as mode of delivery, birth weight, mother's age and body mass index were not seen in our patients.

CONCLUSION

Close observation during the first hours of life is essential and can be life-saving, especially during early skin-to-skin contact.

Implementing skin-to-skin contact at birth using the Iowa model: applying evidence to practice

Prolonged skin-to-skin contact (SSC) between mothers and newborns in the hour after birth is associated with physiologic and psychological benefits for both mothers and infants, yet this is not a standard practice at all birthing facilities. The purpose of the project described in this article was to implement SSC immediately aft er birth for healthy term newborns as a routine, evidence-based practice in a labor and delivery unit at a Midwestern U.S. academic medical center. When incorporated into routine newborn care, SSC promotes key maternal-infant health outcomes of importance to quality nursing care.

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.