Salivary cortisol and behavioral state responses of healthy newborn infants to tactile-only and multisensory interventions

Assessment of cortisol as a neonatal pain biomarker in the application of non-pharmacological analgesia therapies: systematic review and meta-analysis

BACKGROUND

In the history of Neonatology, decades ago pain has been little studied because it was believed that newborns didn't have the capacity to experience pain. Nowadays, there is enough evidence for the existence of neonatal pain but its adequate treatment is an aspect that is continuously evolving. The objective of this study was to evaluate the effectiveness of non-pharmacological analgesia therapies used to alleviate pain in newborns by analysing neonatal cortisol levels as biological markers of pain.

METHODS

A systematic review and meta-analysis was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and the Cochrane Collaboration Handbook. Searches were performed in databases such as PubMed, Web of Science, Scopus, CINAHL, Cochrane Library and Science Direct until the end of May 2024. The search identified 1075 articles, of which 10 studies met the inclusion criteria and had the necessary data to develop the meta-analysis. Furthermore, in each meta-analysis, subgroups were performed: non-pharmacological analgesia vs. placebo, and pre-post intervention by gestational age.

RESULTS

The meta-analysis found that breastfeeding exhibited a moderate effect size (SMD = -0.63; 95% CI = -1.07 to -0.19), sucrose showed a small effect (SMD = -0.15; 95% CI = -0.55 to 0.26), and skin to skin contact exhibited a large effect (SMD = -1.34; 95% CI = -2.21 to -0.46). Patients under 28 weeks have less post-intervention pain and showed a large effect (SMD = 1.44; 95% CI = 0.47 to 2.40), between 28 and 32 weeks they have more post-intervention pain and presented a small effect (SMD = -0.43; 95% CI = -0.86 to -0.0), and over 32 weeks they have an increased post-intervention pain and exhibited a large effect (SMD = -1.08; 95% CI = -1.65 to -0.51).

CONCLUSIONS

Non-pharmacological therapies showed efficacy in pain reduction based on neonatal cortisol levels. Skin to skin contact is the most effective method to reduce pain from invasive procedures, such as heel pricks in preterm infants under 28 weeks. Breastfeeding also demonstrated to be an effective and safe alternative to use for pain relief and to reduce cortisol levels. However, the cortisol results indicate that sucrose was not effective in reducing neonatal pain.

TRIAL REGISTRATION

PROSPERO: CRD42023463831.

A Randomized, Double Blind, Sham-Controlled Clinical Trial to Evaluate the Efficacy of Electrical Vestibular Nerve Stimulation (VeNS), Compared to a Sham Control for Generalized Anxiety Disorder

Aims and Objectives: It has been hypothesised that vestibular stimulation may have a modulatory effect on anxiety. The aim of this randomised, double blind, sham-controlled trial was to determine the efficacy and safety of a non-invasive electrical vestibular nerve stimulation (VeNS) device as a treatment for anxiety compared to a sham stimulation device. Materials and methods: A total of 60 participants (mean age [SD]: 35.6 [8.1]) with a generalized anxiety disorder assessment (GAD-7) score of ≥10 were randomised to receive either an active VeNS device (n = 34) or a sham control device (n = 26). Both groups were asked to complete 20 stimulation sessions (30 min duration) at a rate of 3-5 sessions per week at a research clinic. The primary outcome was change in GAD-7 score from baseline to the end of study (when each participant finished their 20 stimulation sessions). Secondary outcomes were change in Insomnia Severity Index (ISI), and the Short Form 36 Health Survey (SF-36) scores (8 domains). Results: One participant allocated to the sham group withdrew from the study. The mean (SD) number of weeks it took to complete the 20 stimulation sessions was 5.8. The active group had a statistically greater reduction in GAD-7 score compared to the sham group (-7.4 versus -2.2, P < .001; respectively). A total of 97% (n = 33) of the active group achieved a clinically meaningful reduction (defined as ≥4-point reduction) in GAD-7 from baseline to the follow up visit compared to 24% (n = 6) of the sham group (P < .001). Additionally, the active group showed a significant improvement in ISI (-4.9 versus 2.2, P < .001) and greater improvements on all eight SF36 domains (P < .001) compared with the sham group. There was no device related reported adverse events. Conclusion: Regular non-invasive electrical vestibular nerve stimulation appears to have a clinically meaningful benefit when used as an intervention for Generalized Anxiety Disorder.

Salivary Cortisol Levels after Hydrotherapy and Land-Based Therapy as a Marker of Stress in Children with Psychomotor Developmental Disorders: A Pilot Study

Background: The number of children experiencing postnatal situations of neurological risk (such as psycho-motor developmental disorders and delays) after birth has increased in recent years. These infants often require multiple pediatric interventions to address functional problems that might generate stress, anxiety, and discomfort. The aim of the present study is to determine whether the level of salivary cortisol, as a stress marker, increases after hydrotherapy and land-based therapy in children at risk of or currently presenting delayed psycho-motor development. Methods: Saliva samples were collected from 25 children (aged 3-36 months) between June 2022 and January 2023 at the Rehabilitation and Physical Medicine Clinical Management Unit of the Virgen de las Nieves University Hospital, Granada, Spain. Three samples were collected from each child, representing baseline, post-hydrotherapy and post-land-based therapy. Result: All salivary cortisol levels were within the normal range. Resting values were the highest, and both modes of therapy decreased salivary cortisol levels. There were no statistically significant differences between the two therapies. Conclusions: Both therapies appear to be useful for treating children with psychomotor developmental disorders without increasing stress during physiotherapy sessions. Although cortisol levels were slightly higher with hydrotherapy than with land-based therapy, this may be due to the small sample size.

Multisensory stimulation for promoting development and preventing morbidity in preterm infants

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the benefits and harms of multisensory stimulation compared to any single sensory intervention or standard care for physical and neurological development in preterm infants.

The effect of the swaddling method on stress levels in newborns administered nasal CPAP

BACKGROUND

This study aims to investigate the effects of the swaddling method on the stress levels in newborns receiving nasal continuous positive airway pressure (nCPAP).

METHODS

The study was conducted between 1 June 2022 and 1 October 2022 with 40 newborns who underwent nCPAP in the second-level Neonatal Intensive Care Unit (NICU) of a city hospital in the Central Anatolia Region of Turkey. Data were collected using a descriptive form, including the characteristics of newborns, a patient follow-up chart, and the Newborn Stress Scale (NSS). The descriptive form, the patient follow-up chart, and the NSS were completed by the researcher 30 min after the nCPAP was started and the first saliva sample was taken. The patient follow-up chart and NSS were completed 30 min after applying the swaddling method and the second saliva sample was collected. The data were analyzed using IBM SPSS Statistics 25.0 package software and presented with number, percentage, mean, standard deviation, min-max, and t-test.

RESULTS

The study found that the mean score of the NSS after the intervention (3.52 ± 2.57) was lower than that before the intervention (10.02 ± 2.05) (p < 0.05). The mean saliva cortisol levels of the newborns after the intervention (4.99 ± 1.89) were lower than before the intervention (5.51 ± 1.65) (p < 0.05). The mean heart (135.50 ± 14.15) and respiratory rates (68.07 ± 10.16) of the newborns after the intervention were lower than those before the intervention (140.82 ± 18.11; 72.95 ± 9.06, respectively) (p < 0.05). There was no difference between the mean oxygen saturation of newborns before and after the intervention (p > 0.05).

CONCLUSIONS

The study showed that the swaddling method played a role in reducing the stress levels in newborns who underwent nCPAP. It is recommended that randomized controlled trials examining the effect of swaddling on the stress levels of newborns who underwent nCPAP be conducted.

Evidence-Based Consensus Recommendations for Skin Care in Healthy, Full-Term Neonates in India

Purpose

Neonatal skin care practices guided by personal experience and preferences might be substantially different across different hospital settings. The aim of this consensus recommendation is to provide clinical practice guidance to healthcare practitioners on evidence-based neonatal skin care practices from delivery-to-discharge, in hospital settings.

Patients and Methods

A Scientific Advisory Board meeting on "Evidence-based Neonatal Skin Care Practices and Protocols" was held in December 2020 with an expert panel comprising neonatologists, pediatricians, obstetricians and gynecologists and pediatric dermatologist. Comprehensive literature search was performed up to 23 March 2021 using PubMed and Google Scholar to retrieve relevant evidence.

Results

Recommendations were developed on critical aspects of skin care in healthy full-term neonates including cleansing at birth, skin-to-skin care, cord care, diaper area care, initial and routine bathing, cleansers and emollients use, and criteria to choose appropriate skin care products. Recommendations include inclusion of skin assessment in routine neonatal care, first bath timing after cardio-respiratory and thermal stabilization, 6-24 hours after birth; bathing with water alone or adding a mild liquid cleanser could be considered appropriate as it does not impact the developing skin barrier; use of emollients is recommended for neonates with higher risk of development of eczema to maintain and enhance skin barrier function and integrity; and inclusion of skin care advice in neonatal discharge checklist. Importance of rigorous quality control, high-quality clinical trials for assessment of baby products, usage of products that are formulated appropriately for newborns, and full label transparency for baby products were highlighted. The panel identified gaps in literature and discussed the scope for future research.

Conclusion

These recommendations may help to standardize evidence-based skin care for healthy full-term neonates in Indian hospital settings to improve the quality of care that neonates receive in hospital and facilitate improvement in overall neonatal health outcomes.

Efficacy of a Vibrating Crib Mattress to Reduce Pharmacologic Treatment in Opioid-Exposed Newborns: A Randomized Clinical Trial

Importance

Pharmacologic agents are often used to treat newborns with prenatal opioid exposure (POE) despite known adverse effects on neurodevelopment. Alternative nonpharmacological interventions are needed.

Objective

To examine efficacy of a vibrating crib mattress for treating newborns with POE.

Design, Setting, and Participants

In this dual-site randomized clinical trial, 208 term newborns with POE, enrolled from March 9, 2017, to March 10, 2020, were studied at their bedside throughout hospitalization.

Interventions

Half the cohort received treatment as usual (TAU) and half received standard care plus low-level stochastic (random) vibrotactile stimulation (SVS) using a uniquely constructed crib mattress with a 3-hour on-off cycle. Study initiated in the newborn unit where newborns were randomized to TAU or SVS within 48 hours of birth. All infants whose symptoms met clinical criteria for pharmacologic treatment received morphine in the neonatal intensive care unit per standard care.

Main Outcomes and Measures

The a priori primary outcomes analyzed were pharmacotherapy (administration of morphine treatment [AMT], first-line medication at both study sites [number of infants treated], and cumulative morphine dose) and hospital length of stay. Intention-to-treat analysis was conducted.

Results

Analyses were performed on 181 newborns who completed hospitalization at the study sites (mean [SD] gestational age, 39.0 [1.2] weeks; mean [SD] birth weight, 3076 (489) g; 100 [55.2%] were female). Of the 181 analyzed infants, 121 (66.9%) were discharged without medication and 60 (33.1%) were transferred to the NICU for morphine treatment (31 [51.7%] TAU and 29 [48.3%] SVS). Treatment rate was not significantly different in the 2 groups: 35.6% (31 of 87 infants who received TAU) and 30.9% (29 of 94 infants who received SVS) (P = .60). Adjusting for site, sex, birth weight, opioid exposure, and feed type, infant duration on the vibrating mattress in the newborn unit was associated with reduction in AMT (adjusted odds ratio, 0.88 hours per day; 95% CI, 0.81-0.93 hours per day). This translated to a 50% relative reduction in AMT for infants who received SVS on average 6 hours per day. Among 32 infants transferred to the neonatal intensive care unit for morphine treatment who completed treatment within 3 weeks, those assigned to SVS finished treatment nearly twice as fast (hazard ratio, 1.96; 95% CI, 1.01-3.81), resulting in 3.18 fewer treatment days (95% CI, -0.47 to -0.04 days) and receiving a mean 1.76 mg/kg less morphine (95% CI, -3.02 to -0.50 mg/kg) than the TAU cohort. No effects of condition were observed among infants treated for more than 3 weeks (n = 28).

Conclusions and Relevance

The findings of this clinical trial suggest that SVS may serve as a complementary nonpharmacologic intervention for newborns with POE. Reducing pharmacotherapy with SVS has implications for reduced hospitalization stays and costs, and possibly improved infant outcomes given the known adverse effects of morphine on neurodevelopment.

Trial Registration

ClinicalTrials.gov Identifier: NCT02801331.

Benefits of maternally-administered infant massage for mothers of hospitalized preterm infants: a scoping review

OBJECTIVES

Infant massage (IM) is a well-studied, safe intervention known to benefit infants born preterm. Less is known about the benefits of maternally-administrated infant massage for mothers of preterm infants who often experience increased rates of anxiety and depression in their infants' first year of life. This scoping review summarizes the extent, nature, and type of evidence linking IM and parent-centered outcomes.

METHODS

The Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for scoping reviews (PRISMA-ScR) protocol was followed using three databases: PubMed, Embase, and CINAHL. Thirteen manuscripts evaluating 11 separate study cohorts met pre-specified inclusion criteria.

RESULTS

Six primary topics related to the influence of infant massage on parent outcomes emerged: 1) anxiety, 2) perceived stress, 3) depressive symptoms, 4) maternal-infant interaction, 5) maternal satisfaction, and 6) maternal competence. Emerging evidence supports that infant massage, when administered by mothers, benefits mothers of preterm infants by reducing anxiety, stress, and depressive symptoms and improving maternal-infant interactions in the short-term, but there is limited evidence to support its effectiveness on these outcomes in longer periods of follow-up. Based on effect size calculations in small study cohorts, maternally-administered IM may have a moderate to large effect size on maternal perceived stress and depressive symptoms.

CONCLUSIONS

Maternally-administered IM may benefit mothers of preterm infants by reducing anxiety, stress, depressive symptoms, and by improving maternal-infant interactions in the short-term. Additional research with larger cohorts and robust design is needed to understand the potential relationship between IM and parental outcomes.

Anxiolytic effects of vestibular stimulation: an update

The vestibular system inhibits both HPA and SAM axis and contributes to the management of anxiety. Both direct and indirect pathways exist in the inhibition of the HPA and SAM axis. In this review article, the authors describe various pathways through which the vestibular system can regulate the HPA and SAM axis activity. Lastly, the authors highlight the need of starting translational research work in this field. Rocking is soothing and this is a universal fact that babies in the swing will calm down and sleep. These soothing effects of vestibular stimulation may be due to the inhibition of cortical and subcortical structures. Vestibular stimulation may be able to manage anxiety through its connections with multiple brain areas. There is a need to undertake translational research in this area to establish strong scientific evidence and recommend implementation of the vestibular stimulation in the management of anxiety.

Early Postpartum Maternal and Newborn Responses to Auditory, Tactile, Visual, Vestibular, and Olfactory Stimuli

OBJECTIVE

To compare maternal psychological well-being, newborn behavior, and maternal and newborn salivary oxytocin (OT) and cortisol before and after two maternally administered multisensory behavioral interventions or an attention control group.

DESIGN

Randomized prospective clinical trial.

SETTING

U.S. Midwest community hospital.

PARTICIPANTS

Newborns and their mothers (n = 102 dyads) participated. Mothers gave birth vaginally at term gestation and had no physical or mental health diagnoses. Newborns with low Apgar scores, receipt of oxygen, suspected infection, or congenital anomalies were excluded.

METHODS

Dyads were randomly assigned to the auditory, tactile, visual, and vestibular (ATVV) intervention, the ATVV with odor from a baby lotion (ATVVO), or the attention control (AC) Group. Maternal psychological well-being, newborn behavior, and endocrine responses (salivary cortisol and OT) were measured before and after the intervention.

RESULTS

Newborns in the ATVV and ATVVO groups exhibited increases in potent engagement behaviors (p < .0001 and p = .001, respectively). Newborns in the AC group exhibited a decrease in potent engagement (p = .013) and an increase in potent disengagement (p = .029). Mothers in the ATVVO group exhibited an increase in OT (p = .01) and the largest change in OT (p = .02) compared to mothers in the ATVV and AC groups. We noted no change in maternal psychological well-being or newborn endocrine responses.

CONCLUSION

Inclusion of an odor via lotion with a behavioral intervention (ATVV) influenced maternal OT more than the behavioral intervention alone. Newborns were behaviorally responsive to the interventions; however, endocrine measures were not associated with intervention changes.

Consequences of Prematurity on Cortisol Regulation and Adjustment Difficulties: A 9-Year Longitudinal Study

A preterm birth represents a stressful event having potentially negative long-term consequences. Thirty-three children born preterm (<33 weeks gestational age) and eleven full-term children participated in a nine-year longitudinal study. Perinatal Risk Inventory (PERI) was used at birth to assess the perinatal stress. Salivary cortisol, collected four times a day over two consecutive days, was measured with radioimmunoassay technique at six months and nine years to assess the hypothalamic-pituitary-adrenal (HPA) axis. Mothers reported post-traumatic symptoms on a self-report questionnaire 12 months after their child's birth and children's adjustment problems at 9 years of child age on the Child Behavior Checklist. Results showed a significant difference in cortisol regulation at nine years between preterm and full-term children but no differences in adjustment problems. Whereas biological factors (i.e., PERI, cortisol regulation at six months) explained cortisol at nine years, maternal post-traumatic symptoms were predictive of adjustment problems in their child. In conclusion, very preterm birth has some long-term consequences on the HPA-axis regulation at nine years. Although cortisol regulation is mostly influenced by biological factors, the presence of maternal post-traumatic symptoms predicts the manifestation of adjustment problems in both groups. This shows the importance of maternal psychological well-being for child development. Further research is needed to understand the exact consequences of premature birth on cortisol regulation and the implication for the child's development and health.

Effects of smelling amniotic fluid on preterm infant's pain and stress during peripheral cannulation: A randomized controlled trial

AIM

To investigate the effect of smelling amniotic fluid on preterm infants' pain and stress caused by peripheral cannulation.

METHODS

This was a randomized controlled trial. The study sample consisted of 80 preterm infants meeting the case selection criteria and infants were randomly assigned to each group. However, in addition to the infants excluded from the study, total number of the infants in all the groups was 61. Infants in the amniotic fluid group smelled amniotic fluid for 15 min before, during, and after the application of peripheral cannulation while those in the control group received routine care during the procedure. The Premature Infant Pain Profile was used to assess their pain levels, and salivary cortisol analysis was performed to evaluate stress levels.

RESULTS

Preterm infants in the amniotic fluid and control groups had similar baseline characteristics. However, the pain levels of infants in the amniotic fluid group were significantly lower than of those in the control group during and after the procedure. After the procedure, cortisol levels of the infants in the amniotic fluid group were lower than of those in the control group, although this difference was not significant.

CONCLUSION

The intervention of smelling amniotic fluid is a practice that can be used for reducing pain and stress of preterm infants during peripheral cannulation.

Non-invasive monitoring of stress biomarkers in the newborn period

The neonatal period is a highly sensitive time span during which stressful experiences may have an influence on later health outcomes. Medical procedures applied to newborn babies during hospitalization are stressors that trigger a physiological and psychological stress response. Stress response has been traditionally evaluated using scores based on behavioural signs such as facial expressions, limb movements, crying, etc., which are subjectively interpreted. Only few studies have employed measurable physiological signs to objectively evaluate the stress response to specific interventions. The aim of this review is to inform of recently developed biochemical methods that allow clinicians to evaluate the stress response to medical procedures performed in the neonatal period in biological samples non-invasively obtained. Stress biomarkers are based on the physiological stress response mediated by the hypophysis-pituitary-adrenal axis and the sympathetic-adreno-medullary systems. Cortisol is at present the most widely employed laboratory determination to measure stress levels. In recent years, sequentially determined salivary cortisol levels have allowed non-invasive monitoring of newborn infants under stressful conditions in the NICU.

Multimodal Neurological Enhancement Intervention for Self-regulation in Premature Infants

BACKGROUND

The neonatal intensive care unit is often a noisy, overstimulating environment that disrupts infants' regulation of physiological and behavioral states and interrupts caregiver bonding; however, infants benefit from early intervention, including the use of multimodal neurological enhancement (MMNE) intervention to provide appropriate neurodevelopmental stimulation. No one has investigated whether it assists infants in self-regulation.

PURPOSE

The purpose of this retrospective longitudinal analysis was to examine the effect of a music therapy intervention, MMNE, on self-regulation of premature infants as measured by changes in heart rate (HR).

METHODS

A convenience sample of 60 premature infants received 486 MMNE sessions provided by a board-certified music therapist (MT-BC). Documentation, taken during routine clinical services, involved recording infant's HRs from the standard monitor for 3 minutes at baseline, during, and after a 20-minute MMNE intervention.

RESULTS

Infants' mean HRs were decreased during and post-MMNE sessions compared with baseline (P < .004 and P < .001, respectively). Furthermore, infants with a baseline HR above 170 had significant decreases both during and after the MMNE session (P < .001 for both time periods).

IMPLICATIONS FOR PRACTICE

Results of this study support the existing body of evidence showing the benefits of MMNE with premature infants. Based on our results, MMNE may help infants develop and demonstrate self-regulation as indicated by maintained HRs during and after the intervention as well as a lowered HR for infants who had high HRs prior to MMNE.

IMPLICATIONS FOR RESEARCH

Further research needs to be done regarding how infants process MMNE and its potential to aid sensory processing.

The evolution of family-centered care: From supporting parent-delivered interventions to a model of family integrated care

There is increasing recognition that parents play a critical role in promoting the health outcomes of low birthweight and preterm infants. Despite a large body of literature on interventions and models to support family engagement in infant care, parent involvement in the delivery of care for such infants is still restricted in many neonatal intensive care units (NICUs). In this article, we propose a taxonomy for classifying parent-focused NICU interventions and parent-partnered care models to aid researchers, clinical teams, and health systems to evaluate existing and future approaches to care. The proposed framework has three levels: interventions to support parents, parent-delivered interventions, and multidimensional models of NICU care that explicitly incorporate parents and partners in the care of their preterm or low birthweight infant. We briefly review the available evidence for interventions at each level and highlight the strong level of research evidence to support the parent-delivered intervention of skin-to-skin contact (also known as the Kangaroo Care position) and for the Kangaroo mother care and family integrated care models of NICU care. We suggest directions for future research and model implementation to improve and scale-up parent partnership in the care of NICU infants.

Acceptability of a family-centered newborn care model among providers and receivers of care in a Public Health Setting: a qualitative study from India

BACKGROUND

Family-centered care (FCC), based on collaborative participation of the family along with a team of health care providers, is found to increase the well-being of sick infants in neonatal critical care units. Over the last 4 years, the neonatal unit of Dr. Ram Manohar Lohia Hospital in Delhi has innovated and developed an implementation framework for FCC. This qualitative study assessed the acceptability of family-centered care among providers and family members of neonates to identify gaps and challenges in implementation.

METHODS

In-depth interviews were conducted among a purposive sample of twelve family members of admitted neonates and six providers to examine their perceptions and experiences regarding FCC.

RESULTS

Family members and providers expressed a positive perception and acceptance of FCC based on the competencies and knowledge acquired by parents and other caregivers of essential newborn care. Family members reported being satisfied with the overall health care experience due to the transparency of care and allowing them to be by their baby's bedside. Limitations in the infrastructure or lack of facilities at the public hospital did not seem to dilute these positive perceptions. Providers also perceived FCC as a good practice to be continued in spite of concerns around sharing of nursery space with parents, the need for constant vigilance of parents' practices in handling of their newborns, and the need for separate, designated nursing staff for FCC.

CONCLUSION

Both providers and receivers of neonatal care found FCC to be an acceptable form of care. Providers identified challenges and suggested possible solutions, such as need of periodic provider sensitization on FCC, improved staff organization, and provision of mother-friendly facilities to enable her to provide around-the-clock care by her baby's bedside. Overcoming these challenges would allow for better integration of FCC within general clinical care in neonatal care units.

Effect of combined music and touch intervention on pain response and β-endorphin and cortisol concentrations in late preterm infants

BACKGROUND

Preterm neonates undergo many painful procedures as part of their standard care in the neonatal intensive care unit. However, pain treatment is inadequate in many of these routine procedures. In the present study, we investigated the impact and mechanism of combined music and touch intervention (CMT) on the pain response in premature infants.

METHODS

Sixty-two preterm neonates (gestational age of <37 weeks) were randomly assigned to either the experimental or control group. Infants in the experimental group underwent painful procedures with CMT, and those in the control group underwent painful procedures without CMT. Blood samples were collected from all infants at the beginning of hospitalization and 2 weeks later to assess the cortisol and β-endorphin concentrations. Differences in the levels of cortisol and β-endorphin between two groups were examined using analysis of covariance (ANCOVA).

RESULTS

In total, 3707 painful procedures were performed on 62 neonates during their hospitalization. The average number of painful procedures in the control group (n = 35.5) was higher than that in the experimental group (n = 29.0) during hospitalization, although no significant difference was reached (P > 0.05). After 2 weeks, the Premature Infant Pain Profile scores were significantly higher in the control group than experimental group (13.000 ± 0.461 vs 10.500 ± 0.850, respectively; P < 0.05). The cortisol concentration was not significantly different between the control and experimental groups either at the beginning of hospitalization (131.000 ± 18.190 vs 237.200 ± 43.860, respectively; P > 0.05) or 2 weeks later (162.400 ± 23.580 vs 184.600 ± 21.170, respectively; P > 0.05). However, the serum β-endorphin concentration was higher in the experimental group than in the control group both at the beginning of hospitalization (1.640 ± 0.390 vs 1.179 ± 0.090, respectively; P < 0.05) and 2 weeks later (2.290 ± 0.740 vs 1.390 ± 0.410, respectively; P < 0.05).

CONCLUSIONS

CMT might decrease the pain response of preterm neonates by significantly improving the β-endorphin concentration, but not the blood cortisol concentration.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN14131492 . Registered on 01 Aug 2016.

Failure of Saliva Sampling in the QF2011 Queensland Flood Study Examining the Effects of Prenatal Maternal Stress on Neonatal Stress Reactivity

The study was designed to investigate the impact of disaster-related prenatal maternal stress on neonates’ reactivity to the routinely administered, painful, newborn screen procedure (heelstick or heel prick). We hypothesized that pregnancy exposure to a flood stressor would affect fetal developmental pathways and subsequently neonatal responses to other stressful events, including the newborn screen. The pregnant women we recruited were affected by sudden onset floods in Queensland, Australia in 2011. Using methods similar to those described in the literature, we collected neonatal saliva immediately prior to the newborn screen and +20 and +40 min afterwards. Saliva sampling was halted after failed saliva collection attempts by trained research staff on 17 newborns. This article discusses reasons for our failure, including the influence of bioethical concerns and the requirement that research activities are compliant with hospital policies as well as the necessity of publishing studies that fail to replicate prior research.

Vestibular Stimulation for Stress Management in Students

INTRODUCTION

Although several methods are developed to alleviate stress among college students, logistic limitations in adopting them have limited their utility.

AIM

Hence, we aimed to test a very practical approach to alleviate stress among college students by achieving vestibular stimulation using swings.

MATERIALS AND METHODS

In this study 60 male and female participants were randomly assigned into vestibular stimulation or control groups. Depression, anxiety, stress scores, sleep quality, heart rate, blood pressure, Autonomic functions, respiratory, haematological, cognitive function, Quality of life were recorded before and after 1(st), 7(th), 14(th), 21(st), 28(th) days of vestibular stimulation.

RESULTS

STAI S and STAI T scores were significantly improved on day 28(th) following vestibular stimulation. Diastolic and mean arterial blood pressure were significantly decreased and remained within normal limits in vestibular group on day 28(th) following vestibular stimulation. Postural fall in blood pressure was significantly improved on day 14 onwards, following vestibular stimulation. Respiratory rate was significantly improved on day 7 onwards, following vestibular stimulation. PSQI sleep disturbance, PSQI sleep latency, PSQI total score and bleeding time was significantly improved following vestibular stimulation.

CONCLUSION

Our study supports the adoption of vestibular stimulation for stress management. Hence, placement of swings in college campuses must be considered, which may be a simple approach to alleviate stress among college students.

Influence of prone positioning on premature newborn infant stress assessed by means of salivary cortisol measurement: pilot study

Objective

This study sought to assess the influence of prone positioning on the stress of newborn premature infants through the measurement of the salivary cortisol concentration and the evaluation of physiological and behavioral responses before and after changes in body positioning.

Methods

Saliva samples were collected from newborn infants at two different times: the first (corresponding to the baseline) after a period of 40 minutes during which the infants were not subjected to any manipulation and were placed in the lateral or supine position, and the second 30 minutes after placement in the prone position. Variables including heart rate, respiratory rate, peripheral oxygen saturation, and the Brazelton sleep score were recorded before, during, and at the end of the period in the prone position.

Results

The sample comprised 16 newborn premature infants (56.3% male) with a gestational age between 26 and 36 weeks, postnatal age between 1 and 33 days, birth weight of 935 to 3,050g, and weight at the time of intervention of 870 to 2,890g. During the intervention, six participants breathed room air, while the remainder received oxygen therapy. The median salivary cortisol concentration was lower in the prone position compared to baseline (0.13 versus 0.20; p=0.003), as was the median Brazelton sleep score (p=0.02). The average respiratory rate was lower after the intervention (54.88±7.15 versus 60±7.59; p=0.0004). The remainder of the investigated variables did not exhibit significant variation.

Conclusion

Prone positioning significantly reduced the salivary cortisol level, respiratory rate, and Brazelton sleep score, suggesting a correlation between prone positioning and reduction of stress in preterm infants.

Influence of H-HOPE intervention for premature infants on growth, feeding progression and length of stay during initial hospitalization

OBJECTIVE

To examine whether premature infants receiving the maternally administered H-HOPE (Hospital to Home Transition-Optimizing Premature Infant's Environment) intervention had more rapid weight gain and growth, improved feeding progression and reduced length of hospital stay, compared with controls.

STUDY DESIGN

Premature infants born at 29-34 weeks gestational age and their mothers with at least two social-environmental risk factors were randomly assigned to H-HOPE intervention (n=88) or an attention control (n=94) groups. H-HOPE consists of a 15-min multisensory intervention (Auditory, Tactile, Visual and Vestibular stimuli) performed twice daily prior to feeding plus maternal participatory guidance on preterm infant behavioral cues.

RESULT

H-HOPE group infants gained weight more rapidly over time than infants in the control group and grew in length more rapidly than control infants, especially during the latter part of the hospital stay.

CONCLUSION

For healthy preterm infants, the H-HOPE intervention appears to improve weight gain and length over time from birth to hospital discharge.

The NICU Parent Risk Evaluation and Engagement Model and Instrument (PREEMI) for neonates in intensive care units

Engagement is a fairly new concept in practice and research and is gaining the interest of federal and private regulators, clinicians, and researchers. In this article, we offer a standard definition and outline an engagement model and an instrument for early prediction and identification of low engagement in at-risk parents of late preterm infants. The Parent Risk Evaluation and Engagement Model and Instrument (PREEMI), its theoretical underpinnings, instrument design, and practical application and future research are discussed.

Maternally administered interventions for preterm infants in the NICU: effects on maternal psychological distress and mother-infant relationship

Although studies have examined the effects of interventions focused on preterm infants, few studies have examined the effects on maternal distress (anxiety, depressive symptoms, post-traumatic stress symptoms, parenting stress) or parenting. This study examined the effects of the auditory-tactile-visual-vestibular (ATVV) intervention and kangaroo care (KC) on maternal distress and the mother-infant relationship compared to an attention control group. 240 mothers from four hospitals were randomly assigned to the three groups. Maternal characteristics in the three groups were similar: 64.1% of ATVV mothers, 64.2% of KC mothers, and 76.5% of control mothers were African American; maternal age averaged 26.3 years for ATVV mothers, 28.1 for KC mothers, and 26.6 for control mothers; and years of education averaged 13.6 for ATVV and KC mothers, and 13.1 for control mothers. Mothers only differed on parity: 68.4% of ATVV and 54.7% of KC mothers were first-time mothers as compared to 43.6% of control mothers. Their infants had a similar mean gestational ages (27.0 weeks for ATVV, 27.2 for KC, and 27.4 for control) and mean birthweights (993 g for ATVV, 1022 for KC, and 1023 for control). Mothers completed questionnaires during hospitalization, and at 2, 6 and 12 months corrected age on demographic characteristics, depressive symptoms, state anxiety, post-traumatic stress symptoms, parenting stress, worry about child health, and child vulnerability (only at 12 months). At 2 and 6 months, 45-min videotapes of mother-infant interactions were made, and the HOME Inventory was scored. Behaviors coded from the videotapes and a HOME subscale were combined into five interactive dimensions: maternal positive involvement and developmental stimulation and child social behaviors, developmental maturity, and irritability. Intervention effects were examined using general linear mixed models controlling for parity and recruitment site. The groups did not differ on any maternal distress variable. Kangaroo care mothers showed a more rapid decline in worry than the other mothers. The only interactive dimensions that differed between the groups were child social behaviors and developmental maturity, which were both higher for kangaroo care infants. Change over time in several individual infant behaviors was affected by the interventions. When mothers reported on the interventions they performed, regardless of group assignment, massage (any form including ATVV) was associated with a more rapid decline in depressive symptoms and higher HOME scores. Performing either intervention was associated with lower parenting stress. These findings suggest that as short-term interventions, KC and ATVV have important effects on mothers and their preterm infants, especially in the first half of the first year.

Preterm infants' orally directed behaviors and behavioral state responses to the integrated H-HOPE intervention

Preterm infants are challenged by immature infant behavioral organization which may negatively influence their ability to oral feed. The purpose of this study was to determine whether the integrated H-HOPE (Hospital to Home: Optimizing the Infant's Environment) intervention would improve infant behavioral organization by increasing the frequency of orally directed behaviors and the proportion of time spent in an alert behavioral state when offered prior to oral feeding. Mother-infant dyads (n=198) were randomly assigned to the H-HOPE intervention or the Attention Control groups. Infants were born at 29-34 weeks gestation and were clinically stable. Mothers had at least two social environmental risk factors such as minority status or less than high school education. H-HOPE is an integrated intervention that included (1) twice-daily infant directed stimulation using the ATVV intervention (auditory, tactile, visual, and vestibular stimuli) and (2) maternal participatory guidance sessions by a nurse-community advocate team. Orally directed behaviors and behavioral states were assessed weekly prior to feeding during hospitalization when infants were able to feed orally. There were no differences between the groups at baseline (Day 0, prior to the initiation of the integrated H-HOPE intervention). We observed a pattern of increased frequency of orally directed behaviors in the H-HOPE intervention group when compared to the Attention Control group, however, the proportion of time spent in an alert behavioral state remained stable in both groups over the course of the study. On Day 7, the H-HOPE intervention group exhibited a significantly higher mean frequency of orally directed behaviors than the Attention Control group (12.6 vs. 7.1 pre-intervention, 51.8 vs. 33.2 during intervention, 4.3 vs. 3.2 immediately after intervention, and 8.9 vs. 5.3 immediately prior to feeding). On Day 7, the H-HOPE intervention group exhibited a significantly higher proportion of time spent in an alert behavioral state only during intervention (0.26 vs. 0.11) and immediately after intervention (0.28 vs. 0.06). These findings are suggestive that the integrated H-HOPE intervention facilitated infant behavioral organization for clinically stable infants born between 29 and 34 weeks gestation. The orally directed behaviors appear to be an important indicator of the infant's preparation for feeding, and when used in conjunction with assessment of behavioral states, are especially valuable to the clinician. Use of this combined assessment approach in practice would strengthen clinician assessment for initiation of (beginning the first oral feeding) and daily preparation for oral feeding in preterm infants.

Does daily kangaroo care provide sustained pain and stress relief in preterm infants?

OBJECTIVES

1. Determine whether stress in preterm infants, measured with salivary cortisol, decreases after five days of Kangaroo Care (KC) compared to five days of Standard Care (SC). 2. To determine whether kangaroo care provides sustainable pain relief beyond the period of skin-to-skin holding.

STUDY DESIGN

Preterm infants (n = 38) born at 27-30 weeks gestational age were randomized to either the KC or the SC group and received the allocated intervention starting on day of life (DOL) five and continuing for five days. Salivary cortisol was collected on DOL five and again on DOL ten. Differences were analyzed using repeated measures ANOVA and t tests. Pain during nasal suctioning over five days was assessed using the Premature Infant Pain Profile (PIPP).

RESULT

1. Adequate saliva samples for salivary cortisol were collected for 13 KC infants and 11 SC infants. There was no main effect of group (p = 0.49), but there was a significant main effect of age (DOL five versus DOL ten), with salivary cortisol levels decreasing in both groups (p = 0.02). 2. Pain scores for both groups (n = 38) indicted mild to moderate pain during suctioning, with no significant difference in pain scores between groups.

CONCLUSION

1. KC did not affect salivary cortisol levels in preterm neonates, but levels in both the KC and SC groups decreased over time from DOL five to ten. Salivary cortisol may vary with age of infant. 2. Infants experience pain during routine suctioning and may require pain management.

Detection and potential utility of C-reactive protein in saliva of neonates

OBJECTIVE

We aimed to detect C-reactive protein (CRP) in neonatal saliva and evaluate its diagnostic utility.

STUDY DESIGN

Salivary and serum samples (n = 89) were collected from 40 neonates. Salivary CRP levels were determined using an enzyme-linked immunosorbent assay; serum CRP was measured per hospital protocol. Correlation coefficients with 95% confidence intervals and robust linear regression measured association while receiver-operator characteristic curves described the accuracy of salivary CRP in discriminating abnormal serum CRP thresholds of ≥10 and 5 mg/L. Corresponding sensitivities and specificities were calculated for these salivary cutpoints.

RESULTS

The area under the curve for salivary CRP in predicting serum CRP levels of ≥10 and 5 mg/L were 0.81 and 0.76, respectively. The corresponding sensitivity and specificity for raw salivary CRP to discriminate a serum CRP of ≥5 mg/L was 0.54 and 0.95, respectively. The corresponding sensitivity and specificity for raw salivary CRP to discriminate a serum CRP of ≥10 mg/L was 0.64 and 0.94, respectively. A statistically significant correlation was observed between serum and salivary CRP (r = 0.62, p < 0.001).

CONCLUSION

C-reactive protein is detectable in neonatal saliva and can predict abnormal serum CRP thresholds. Salivary CRP analysis represents a feasible screening tool for detecting abnormal serum CRP levels.

Benefits of massage therapy for infants with symptoms of gastroesophageal reflux disease

OBJECTIVES

This randomized controlled pilot trial was conducted to evaluate the clinical efficacy of massage therapy (MT) for relief of symptoms of gastroesophageal reflux disease (GERD). The hypothesis was that, when compared to infants who received nonmassage therapy, infants who received MT would display fewer GERD symptoms, greater weight gain, greater amount of sleep, lower cortisol levels before and after treatment, and lower daily (area under the curve [AUC]) cortisol secretion.

METHODS

Participants were 36 infants born at term, 4-10 weeks of age at enrollment, healthy except for a diagnosis of GERD by their pediatrician, and with a score of at least 16 on the Infant Gastroesophageal Reflux Questionnaire-Revised (I-GERQ-R). Infants were randomized to receive either MT or a nonmassage sham treatment in their homes for 30 min twice a week for 6 weeks. Data collectors and parents were blind to study condition.

RESULTS

GERD symptoms decreased in both groups and weight increased. Pretreatment salivary cortisol levels decreased significantly over time in the massage group while increasing in the nonmassage group. Daily cortisol level also decreased in the massage group and increased in the nonmassage group, but the difference was not significant.

CONCLUSIONS

MT administered by a professional therapist did not affect symptoms of GERD differently than a sham treatment but did decrease infant stress as measured by cortisol. Research focusing on stress reduction in infants with GERD and multimodal treatments addressing GERD symptoms may yield the most effective treatment.

Massage for promoting mental and physical health in typically developing infants under the age of six months

BACKGROUND

Infant massage is increasingly being used in the community with babies and their primary caregivers. Anecdotal reports suggest benefits for sleep, respiration and elimination, the reduction of colic and wind, and improved growth. Infant massage is also thought to reduce infant stress and promote positive parent-infant interaction.

OBJECTIVES

The aim of this review was to assess whether infant massage is effective in promoting infant physical and mental health in low-risk, population samples.

SEARCH METHODS

Relevant studies were identified by searching the following electronic databases up to June 2011: CENTRAL; MEDLINE; EMBASE; CINAHL; PsycINFO; Maternity and Infant Care; LILACS; WorldCat (dissertations); ClinicalTrials.gov; China Masters' Theses; China Academic Journals; China Doctoral Dissertations; China Proceedings of Conference. We also searched the reference lists of relevant studies and reviews.

SELECTION CRITERIA

We included studies that randomised healthy parent-infant dyads (where the infant was under the age of six months) to an infant massage group or a 'no-treatment' control group. Studies had to have used a standardised outcome measure of infant mental or physical development.

DATA COLLECTION AND ANALYSIS

Mean differences (MD) and standardised mean differences (SMD) and 95% confidence intervals (CIs) are presented. Where appropriate, the results have been combined in a meta-analysis using a random-effects model.

MAIN RESULTS

We included 34 studies, which includes one that was a follow-up study and 20 that were rated as being at high risk of bias.We conducted 14 meta-analyses assessing physical outcomes post-intervention. Nine meta-analyses showed significant findings favouring the intervention group for weight (MD -965.25 g; 95% CI -1360.52 to -569.98), length (MD -1.30 cm; 95% CI -1.60 to -1.00), head circumference (MD -0.81 cm; 95% CI -1.18 to -0.45), arm circumference (MD -0.47 cm; 95% CI -0.80 to -0.13), leg circumference (MD -0.31 cm; 95% CI -0.49 to -0.13), 24-hour sleep duration (MD -0.91 hr; 95% CI -1.51 to -0.30), time spent crying/fussing (MD -0.36; 95% CI -0.52 to -0.19), deceased levels of blood bilirubin (MD -38.11 mmol/L; 95% CI -50.61 to -25.61), and there were fewer cases of diarrhoea, RR 0.39; 95% CI 0.20 to 0.76). Non-significant results were obtained for cortisol levels, mean increase in duration of night sleep, mean increase in 24-hour sleep and for number of cases of upper respiratory tract disease and anaemia.Sensitivity analyses were conducted for weight, length and head circumference, and only the finding for length remained significant following removal of studies judged to be at high risk of bias. These three outcomes were the only ones that could also be meta-analysed at follow-up; although both weight and head circumference continued to be significant at 6-month follow-up, these findings were obtained from studies conducted in Eastern countries only. No sensitivity analyses were possible.We conducted 18 meta-analyses measuring aspects of mental health and development. A significant effect favouring the intervention group was found for gross motor skills (SMD -0.44; 95% CI -0.70 to -0.18), fine motor skills (SMD -0.61; 95% CI -0.87 to -0.35), personal and social behaviour (SMD -0.90; 95% CI -1.61 to -0.18) and psychomotor development (SMD -0.35; 95% CI -0.54 to -0.15); although the first three findings were obtained from only two studies, one of which was rated as being at high risk of bias, and the finding for psychomotor development was not maintained following following removal of studies judged to be at high risk of bias in a sensitivity analysis. No significant differences were found for a range of aspects of infant temperament, parent-infant interaction and mental development. Only parent-infant interaction could be meta-analysed at follow-up, and the result was again not significant.

AUTHORS' CONCLUSIONS

These findings do not currently support the use of infant massage with low-risk groups of parents and infants. Available evidence is of poor quality, and many studies do not address the biological plausibility of the outcomes being measured, or the mechanisms by which change might be achieved. Future research should focus on the impact of infant massage in higher-risk groups (for example, demographically and socially deprived parent-infant dyads), where there may be more potential for change.

The crying baby: what approach?

PURPOSE OF REVIEW

Cry-fuss problems are among the most common clinical presentations in the first few months of life and are associated with adverse outcomes for some mothers and babies. Cry-fuss behaviour emerges out of a complex interplay of cultural, psychosocial, environmental and biologic factors, with organic disturbance implicated in only 5% of cases. A simplistic approach can have unintended consequences. This article reviews recent evidence in order to update clinical management.

RECENT FINDINGS

New research is considered in the domains of organic disturbance, feed management, maternal health, sleep management, and sensorimotor integration. This transdisciplinary approach takes into account the variable neurodevelopmental needs of healthy infants, the effects of feeding management on the highly plastic neonatal brain, and the bi-directional brain-gut-enteric microbiota axis. An individually tailored, mother-centred and family-centred approach is recommended.

SUMMARY

The family of the crying baby requires early intervention to assess for and manage potentially treatable problems. Cross-disciplinary collaboration is often necessary if outcomes are to be optimized.

Comparison of salivary cortisol, heart rate, and oxygen saturation between early skin-to-skin contact with different initiation and duration times in healthy, full-term infants

BACKGROUND

There are few studies that compare the physiological and biological efficacies between different early skin-to-skin contacts (SSC) post birth.

AIM

To investigate physiologically and biochemically how early SSC with different initiation and duration time influence the stress post birth for full-term infants.

STUDY DESIGN

Non-experimental study.

SUBJECTS

Study I; Thirty-two infants who began SSC 5 min or less [birth SSC, mean initiation time (standard deviation): 1.6 (1.1) min] after birth and 36 infants who did so more than 5 min [very early SSC, 26.3 (5.0) min] in heart rate (HR) and oxygen saturation (SpO(2)) analysis. Study II; Eighteen infants who underwent SSC for 60 min or less [mean initiation time: 7.5 (12.2) min] and 61 infants who did so for more than 60 min [15.3 (12.5) min] in salivary cortisol analysis.

OUTCOME MEASURES

HR and SpO(2) measured for 30 min post birth. Salivary cortisol concentration measured at 1 min, 60 min, and 120 min post birth.

RESULTS

Birth SSC group reached HR stability of 120-160 bpm significantly faster than very early SSC group by Kaplan-Meier analysis (P=0.001 by log-rank test). As for SpO(2) stability of 92% and 96%, no significantly between-group difference was found. Salivary cortisol levels were significantly lower between 60 and 120 min after birth in SSC group, continuing for more than 60 min compared with SSC group for 60 min or less after adjustment for salivary cortisol level at 1 min besides the infant stress factors (P=0.046).

CONCLUSIONS

Earlier SSC beginning within 5 min post birth and longer SSC continuing for more than 60 min within 120 min post birth are beneficial for stability of cardiopulmonary dynamics and the reduction of infant stress during the early period post birth.

Impact of intimate partner violence on maternal child health

This article synthesizes research that has examined the impact of abuse on women, fetuses, and developing children. Intimate partner violence affects the lives of millions of women, sometimes in ways we have yet to understand. Despite the research in this area, the full impact of abuse on the long-term physical and psychosocial well-being of women and their families is not fully understood. There are data, however, that suggest that lifelong health changes may be linked to patterns of abuse. Intimate partner violence during pregnancy has an impact on not only the woman but the developing fetus and the extended family. It is essential that all women be screened for intimate partner violence, and that nurses understand interventions that have been shown to be effective for this group of patients.

A model of neurodevelopmental risk and protection for preterm infants

The purpose of this article is to introduce a model of neurodevelopmental risk and protection that may explain some of the relationships among biobehavioral risks, environmental risks, and caregiving behaviors that potentially contribute to neurobehavioral and cognitive outcomes. Infants born before 30 weeks of gestation have the poorest developmental prognosis of all infants. These infants have lengthy hospitalization periods in the neonatal intensive care unit (NICU,) an environment that is not always supportive of brain development and long-term developmental needs. The model supports the premise that interventions focused on neuroprotection during the neonatal period have the potential to positively affect long-term developmental outcomes for vulnerable very preterm infants. Finding ways to better understand the complex relationships among NICU-based interventions and long-term outcomes are important to guiding caregiving practices in the NICU.