Oxidative Stress Biomarker Decreased in Preterm Neonates Treated With Kangaroo Mother Care

Analysis of the implementation of the Kangaroo Method in a tertiary maternity hospital in Recife, Brazil

OBJECTIVE

To analyze the implementation of the Kangaroo Method in a tertiary maternity hospital in the city of Recife.

METHOD

Evaluative research analyzing the implementation of the 2nd and 3rd stages of the Kangaroo Method. Conducted between November 2021 and May 2022. A logical model of the Kangaroo Method and the respective matrix of indicators were developed, validated by the Delphi technique, referring to the structure, process, definers of the degree of implementation (implemented/partially implemented/incipient), and the outcomes. Professionals from the Kangaroo Unit (n=9), discharge clinic (n=2), basic health units (n=15), municipal manager (n=1) and parents (n=18) were interviewed; medical records were checked along with direct observation. Plausibility relations were established using a deductive approach based on the logical model to compare the degree of implementation of the Kangaroo Method with its outcomes.

RESULTS

The 2nd stage was partially implemented (79.2%), as was its integration with the 3rd stage (78.0%). The implementation of the 3rd stage was incipient (58.4%). The mothers adhered to the recommended care and a strengthened bond with their babies (100%). The children were followed up at the discharge clinic (100%), but only 38.8% are in primary health care. Professionals were trained in the maternity ward (90%) and in primary care (37.5%).

CONCLUSION

The Kangaroo Method was partially implemented, showing greater fragility in follow-up after hospital discharge.

Kangaroo Mother Care on Perfusion Index, Heart Rate, and Oxygen Saturation in Premature Infants Who were Discharged Early and Admitted to The Neonatal Intensive Care Unit: A Randomized Control Tria

Aim

To determine the effect of kangaroo mother care (KMC) on perfusion index, heart rate, and oxygen saturation in premature infants who were discharged early and admitted to the neonatal intensive care unit (NICU) in the following days.

Methods

This study has a randomized controlled experimental design and uses a pretest-posttest control group model. This study included infants between December 2019 and December 2020 who were discharged early and subsequently admitted to the NICU. Experimental (n=38) and control (n=38) groups were assigned using the simple randomization technique at the NICU of a private university hospital in Istanbul, Türkiye. Heart rate, perfusion index, and oxygen saturation levels of the experimental group in which KMC was applied and the control group in which KMC was not applied were compared. Measurements of these parameters were made at 15-minute intervals for 45 minutes (0-1, 15, 30, 45 minutes). Data were collected via the Mother and Infant Introductory Information Form, Kangaroo Mother Care Preparation Checklist, Kangaroo Mother Care Physiological Parameter Monitoring Form, and Noninvaziv Pulse Co-Oximetry. Statistics of these data were performed with the independent sample t-test, Pearson's Chi-square, Fisher's exact test.

Results

In the experimental and control groups, infants' gestational age (31.11 ± 3.25 and 31.61 ± 3.04, respectively; p = .491) and weight (1778.29 ± 436.93 and 1953.29 ± 345.74, respectively; p = .057) were similar, and the differences were statistically insignificant. Before KMC, there was no difference between the heart rate, oxygen saturation, and perfusion index values of the experimental and control groups (p > .05). From the first 15 minutes after the application of KMC to 45 minutes post-KMC, there was a significant decrease in (p=0.001) and stabilization of heart rate and oxygen saturation in the experimental group compared with the control group. The heart rates in the experimental group at 15th, 30th, and 45th minutes during KMC were lower than in the control group (147.63 ± 11.04; 142.47 ± 11.94; 136.82 ± 13.22 and 153.13 ± 8.73; 154.50 ± 7.27; 154.84 ± 7.05, respectively). Also, their oxygen saturation during KMC was higher than in the control group (96.68 ± 2.08; 97.24 ± 2.18; 97.87 ± 1.66 and 94.79 ± 1.27; 94.66 ± 1.45; 94.39 ± 1.38, respectively). This significant difference between KMC on heart rate and oxygen saturation in the experimental group compared to the control group continued for 45 minutes after KMC. The perfusion index was significantly higher at 30 minutes and 45 minutes during KMC. However, although it continued after KMC, this change in perfusion index was not statistically significant.

Conclusion

Kangaroo mother care helps to regulate the heart rate, oxygen saturation, and perfusion index of premature infants who were discharged early and admitted to the NICU in the following days.

Eligible Infants Included in Neonatal Clinical Trials and Reasons for Noninclusion: A Systematic Review

Importance

Results of clinical trials can only represent included participants, and many neonatal trials fail due to insufficient participation. Infants not included in research may differ from those included in meaningful ways, biasing the sample and limiting the generalizability of findings.

Objective

To describe the proportion of eligible infants included in neonatal clinical trials and the reasons for noninclusion.

Evidence Review

A systematic search of Cochrane CENTRAL was performed by retrieving articles meeting the following inclusion criteria: full-length, peer-reviewed articles describing clinical trial results in at least 20 human infants from US neonatal intensive care units, published in English, and added to Cochrane CENTRAL between 2017 and 2022. Retrieved articles were screened for inclusion by 2 independent researchers.

Findings

In total 120 articles met inclusion criteria and 91 of these (75.8%) reported the number of infants eligible for participation, which totaled 26 854 in aggregate. Drawing from these, an aggregate of 11 924 eligible infants (44.4%) were included in reported results. Among all eligible infants, most reasons for noninclusion in results were classified as modifiable or potentially modifiable by the research team. Parents declining to participate (8004 infants [29.8%]) or never being approached (2507 infants [9.3%]) were the 2 predominant reasons for noninclusion. Other modifiable reasons included factors related to study logistics, such as failure to appropriately collect data on enrolled infants (859 of 26 854 infants [3.2%]) and other reasons (1907 of 26 854 infants [7.1%]), such as loss to follow-up or eligible participants that were unaccounted for. Nonmodifiable reasons, including clinical change or death, accounted for a small proportion of eligible infants who were not included (858 of 26 854 infants [3.2%]).

Conclusions and Relevance

This systematic review of reporting on eligible infants included and not included in neonatal clinical trials highlights the need for improved documentation on the flow of eligible infants through neonatal clinical trials and may also inform recruitment expectations for trialists designing future protocols. Improved adherence to standardized reporting may clarify which potential participants are being missed, improving understanding of the generalizability of research findings. Furthermore, these findings suggest that future work to understand why parents decline to participate in neonatal research trials and why some are never approached about research may help increase overall participation.

AZIN2 is associated with apoptosis of germ cells in undescended testis

Undescended testis (UDT), known as cryptorchidism (CRY), is a common congenital disorder in which one or both testicles do not descend normally into the scrotum. A unilateral UDT model was established by inducing UDT in mice through surgery. The results showed that the testis in the UDT model group was abnormal; the lumen of the seminiferous tubule was atrophic; apoptosis, necrosis and shedding were observed in many of the germ cells; the level of sex hormones was abnormal; and mature sperm was reduced. Subsequently, transcriptome sequencing was conducted on the testicular tissue of UDT model mice. Through analysis and verification of differential genes, AZIN2 was identified as playing a key role in the decline in male fertility caused by cryptorchidism. AZIN2 expression and spermine content was down-regulated in the testis of the UDT group. We then used a combination of hypoxanthine and xanthine to create a GC-1 cell damage model. In this model, AZIN2 expression and spermine content was down-regulated. When si-Azin2 transfected GC-1 cells, cell viability and proliferation were decreased. However, in the GC-1 cell damage model transfected with Azin2 over-expressed plasmid, AZIN2 expression and spermine content was up-regulated, reversing the cell damage caused by hypoxanthine and xanthine, and restoring the proliferation ability of GC-1 cells. These results indicate that in UDT, down-regulated AZIN2 expression is a factor in testicular damage. This discussion of the connection between AZIN2 and germ cells has important clinical significance as it provides an important reference for the diagnosis and treatment of cryptorchidism.

New policies on skin-to-skin contact warrant an oxytocin-based perspective on perinatal health care

Background

In 2023, the World Health Organization (WHO) published a Global Position Paper on Kangaroo Mother Care (KMC), which is applicable to all countries worldwide: from the moment of birth, every "small and sick" newborn should remain with mother in immediate and continuous skin-to-skin contact (SSC), receiving all required clinical care in that place. This was prompted by the startling results of a randomized controlled trial published in 2021: in which 1,609 infants receiving immediate SSC were compared with 1,602 controls that were separated from their mothers but otherwise received identical conventional state-of-the-art care. The intervention infants showed a 25% reduction in mortality after 28 days.

New perspectives

The new WHO guidelines are a significant change from earlier guidance and common clinical practice. The author presents that separating mothers and babies is assumed to be "normal" (a paradigm) but actually puts newborns at increased risk for morbidity and mortality. The author presents arguments and ethical perspectives for a new perspective on what is "normal," keeping newborns with their mothers is the infant's physiological expectation and critical requirement for healthy development. The author reviews the scientific rationale for changing the paradigm, based on synchronous interactions of oxytocin on both mother and infant. This follows a critique of the new policies that highlights the role of immediate SSC.

Actionable recommendations

This critique strengthens the case for implementing the WHO guidelines on KMC for small and sick babies. System changes will be necessary in both obstetric and neonatal settings to ensure seamless perinatal care. Based on the role of oxytocin, the author identifies that many current routine care practices may actually contribute to stress and increased vulnerability to the newborn. WHO has actionable recommendations about family involvement and presence in newborn intensive care units.

Discussion

The concepts of resilience and vulnerability have specific definitions well known in perinatal care: the key outcome of care should be resilience rather than merely the absence of vulnerability. Newborns in all settings and contexts need us to re-evaluate our paradigms and adopt and implement the new WHO guidelines on KMC in perinatal care.

The Urinary Metabolome of Newborns with Perinatal Complications

Maternal pathological conditions such as infections and chronic diseases, along with unexpected events during labor, can lead to life-threatening perinatal outcomes. These outcomes can have irreversible consequences throughout an individual's entire life. Urinary metabolomics can provide valuable insights into early physiological adaptations in healthy newborns, as well as metabolic disturbances in premature infants or infants with birth complications. In the present study, we measured 180 metabolites and metabolite ratios in the urine of 13 healthy (hospital-discharged) and 38 critically ill newborns (admitted to the neonatal intensive care unit (NICU)). We used an in-house-developed targeted tandem mass spectrometry (MS/MS)-based metabolomic assay (TMIC Mega) combining liquid chromatography (LC-MS/MS) and flow injection analysis (FIA-MS/MS) to quantitatively analyze up to 26 classes of compounds. Average urinary concentrations (and ranges) for 167 different metabolites from 38 critically ill NICU newborns during their first 24 h of life were determined. Similar sets of urinary values were determined for the 13 healthy newborns. These reference data have been uploaded to the Human Metabolome Database. Urinary concentrations and ranges of 37 metabolites are reported for the first time for newborns. Significant differences were found in the urinary levels of 44 metabolites between healthy newborns and those admitted at the NICU. Metabolites such as acylcarnitines, amino acids and derivatives, biogenic amines, sugars, and organic acids are dysregulated in newborns with bronchopulmonary dysplasia (BPD), asphyxia, or newborns exposed to SARS-CoV-2 during the intrauterine period. Urine can serve as a valuable source of information for understanding metabolic alterations associated with life-threatening perinatal outcomes.

Race and Ethnicity of Infants Enrolled in Neonatal Clinical Trials: A Systematic Review

Importance

Representativeness of populations within neonatal clinical trials is crucial to moving the field forward. Although racial and ethnic disparities in research inclusion are well documented in other fields, they are poorly described within neonatology.

Objective

To describe the race and ethnicity of infants included in a sample of recent US neonatal clinical trials and the variability in this reporting.

Evidence Review

A systematic search of US neonatal clinical trials entered into Cochrane CENTRAL 2017 to 2021 was conducted. Two individuals performed inclusion determination, data extraction, and quality assessment independently with discrepancies adjudicated by consensus.

Findings

Of 120 studies with 14 479 participants that met the inclusion criteria, 75 (62.5%) included any participant race or ethnicity data. In the studies that reported race and ethnicity, the median (IQR) percentage of participants of each background were 0% (0%-1%) Asian, 26% (9%-42%) Black, 3% (0%-12%) Hispanic, 0% (0%-0%) Indigenous (eg, Alaska Native, American Indian, and Native Hawaiian), 0% (0%-0%) multiple races, 57% (30%-68%) White, and 7% (1%-21%) other race or ethnicity. Asian, Black, Hispanic, and Indigenous participants were underrepresented, while White participants were overrepresented compared with a reference sample of the US clinical neonatal intensive care unit (NICU) population from the Vermont Oxford Network. Many participants were labeled as other race or ethnicity without adequate description. There was substantial variability in terms and methods of reporting race and ethnicity data. Geographic representation was heavily skewed toward the Northeast, with nearly one-quarter of states unrepresented.

Conclusions and Relevance

These findings suggest that neonatal research may perpetuate inequities by underrepresenting Asian, Black, Hispanic, and Indigenous neonates in clinical trials. Studies varied in documentation of race and ethnicity, and there was regional variation in the sites included. Based on these findings, funders and clinical trialists are advised to consider a 3-point targeted approach to address these issues: prioritize identifying ways to increase diversity in neonatal clinical trial participation, agree on a standardized method to report race and ethnicity among neonatal clinical trial participants, and prioritize the inclusion of participants from all regions of the US in neonatal clinical trials.

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

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

Effect on neonatal sepsis following immediate kangaroo mother care in a newborn intensive care unit: a post-hoc analysis of a multicentre, open-label, randomised controlled trial

Background

To implement the immediate Kangaroo mother care (iKMC) intervention in the previous multicentre, open-label, randomised controlled trial, the mother or a surrogate caregiver and neonate needed to be together continuously, which led to the concept of the Mother-Newborn Care Unit (MNCU). Health-care providers and administrators were concerned of the potential increase in infections caused by the continuous presence of mothers or surrogates in the MNCU. We aimed to assess the incidence of neonatal sepsis in sub-groups and the bacterial profile among intervention and control neonates in the study population.

Methods

This is a post-hoc analysis of the previous iKMC trial, which was conducted in five level 2 Newborn Intensive Care Units (NICUs) one each in Ghana, India, Malawi, Nigeria, and Tanzania, in neonates with birth weight 1 to <1.8 kg. The intervention was KMC initiated immediately after birth and continued until discharge and compared to conventional care with KMC initiated after meeting stability criteria. The primary outcomes of this report were the incidence of neonatal sepsis in sub-groups, sepsis-related mortality and bacterial profile of isolates during hospital stay. The original trial is registered with the Australia and New Zealand Clinical Trials Registry (ACTRN12618001880235) and the Clinical Trials Registry-India (CTRI/2018/08/01536).

Findings

Between November 30, 2017, and January 20, 2020, 1609 newborns in the intervention group and in the control group 1602 newborns were enrolled in iKMC study. 1575 newborns in the intervention group and 1561 in the control group were clinically evaluated for sepsis. Suspected sepsis was 14% lower in intervention group in sub-group of neonates with birth weight 1.0-<1.5 kg; RR 0.86 (CI 0.75, 0.99). Among neonates with birth weight 1.5-<1.8 kg, suspected sepsis was reduced by 24%; RR 0.76 (CI 0.62, 0.93). Suspected sepsis rates were lower in intervention group than in the control group across all sites. Sepsis related mortality was 37% less in intervention group than the control group; RR 0.63 (CI 0.47-0.85) which was statistically significant. The intervention group had fewer cases of Gram-negative isolates (n = 9) than Gram positive isolates (n = 16). The control group had more cases of Gram-negative isolates (n = 18) than Gram positive (n = 12).

Interpretation

Immediate Kangaroo Mother care is an effective intervention to prevent neonatal sepsis and sepsis related mortality.

Funding

The original trial was funded by the Bill and Melinda Gates Foundation through a grant to the World Health Organization (grant No. OPP1151718).

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

IMPLICATIONS FOR PRACTICE AND RESEARCH

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

Immediate skin-to-skin contact may have beneficial effects on the cardiorespiratory stabilisation in very preterm infants

AIM

Our aim was to investigate what effect immediate skin-to-skin contact with a parent had on the cardiorespiratory stabilisation of very preterm infants.

METHODS

This randomised clinical trial was conducted during 2018-2021 at two university hospitals with three neonatal intensive care units in Norway and Sweden. Infants born from 28+0 to 32+6 weeks of gestation were randomised to immediate skin-to-skin contact with a parent for the first six postnatal hours or standard incubator care. The outcome was a composite cardiorespiratory stability score, based on serial measures of heart and respiratory rate, respiratory support, fraction of inspired oxygen and oxygen saturation.

RESULTS

We recruited 91 newborn infants with a mean gestational age of 31+1 (range 28+4-32+6) weeks and mean birth weight of 1534 (range 555-2440) g: 46 received immediate skin-to-skin contact and 45 received incubator care. The group who received skin-to-skin contact had an adjusted mean score of 0.52 higher (95% confidence interval 0.38-0.67, p < 0.001) on a scale from zero to six when compared to the control group.

CONCLUSION

Immediate skin-to-skin contact for the first six postnatal hours had beneficial effects on the cardiorespiratory stabilisation of very preterm infants.

Effects of Kangaroo Mother Care in the NICU on the Physiological Stress Parameters of Premature Infants: A Meta-Analysis of RCTs

OBJECTIVE

The aim of this study was to analyze the randomised controlled trials that explored the effect of kangaroo mother care on physiological stress parameters of premature infants.

METHODS

Two independent researchers performed a systematic review of indexed studies in PubMed, Embase, CINAHL, Cochrane and Scopus. We included data from randomized controlled trials measuring the effects of kangaroo care compared to standard incubator care on physiological stress outcomes, defined as oxygen saturation, body temperature, heart rate and respiratory rate. The PRISMA model was used to conduct data extraction. We performed a narrative synthesis of all studies and a meta-analysis when data were available from multiple studies that compared the same physiological parameters with the kangaroo method as an intervention and controls and used the same outcome measures.

RESULTS

Twelve studies were eligible for inclusion in this meta-analysis. According to statistical analysis, the mean respiratory rate of preterm infants receiving KMC was lower than that of infants receiving standard incubator care (MD, -3.50; 95% CI, -5.17 to -1.83; p < 0.00001). Infants who received kangaroo mother care had a higher mean heart rate, oxygen saturation and temperature, although these results were not statistically significant.

CONCLUSIONS

Current evidence suggests that kangaroo care in the neonatal intensive care unit setting is a safe method that may have a significant effect on some of the physiological parameters of stress in preterm infants. However, due to clinical heterogeneity, further studies are needed to assess the effects of physiological stress in the neonatal intensive care unit on the development of preterm infants.

A pilot study on the biochemical effects of repeated administration of 24% oral sucrose vs. 30% oral dextrose on urinary markers of adenosine triphosphate degradation

OBJECTIVES

Premature neonates often receive oral sucrose or dextrose before tissue-damaging procedures (TDPs). Previous work showed that a single dose of sucrose, but not dextrose, increased cellular energy utilization and ATP degradation. This pilot study probes the effects of repeated administration of sucrose or dextrose on energy metabolism.

METHODS

Urinary markers of ATP metabolism (hypoxanthine, xanthine, uric acid) are measured in premature neonates randomized to receive: (a) standard of care, (b) 0.2 ml 24% oral sucrose, or (c) 0.2 ml 30% oral dextrose, before every painful procedure on days-of-life 3-7.

RESULTS

Standard of care is associated with highest xanthine/creatinine and uric acid/creatinine, likely because of fewer pain treatments. Benefits of repeated oral sucrose are unclear. Neonates receiving oral dextrose had lower xanthine/creatinine and uric acid/creatinine.

CONCLUSIONS

Repeated treatments of neonatal procedural pain with 30% oral dextrose are less energetically demanding. Larger clinical studies are needed for comparison with sucrose treatments.

Non-invasive monitoring of saliva can be used to identify oxidative stress biomarkers in preterm and term newborn infants

AIM

The aim of this study was to appraise the feasibility and reproducibility of applying a validated analytical method to determine salivary oxidative stress biomarkers in newborn infants.

METHODS

Prospective observational single-centre study was carried out in level III neonatal intensive care unit. Eligible patients were preterm infants and healthy full-term newborn infants. Salivary samples were analysed in the chromatographic system.

RESULTS

A total of 23 premature newborn infants and 13 full-term newborns were included. We analysed salivary levels of oxidative stress biomarkers for 5-F_2t isoprostane, 15-E_2t isoprostane, prostaglandin E₂ and prostaglandin F2α. The multivariate predictive model showed a positive association between female and 5-F_2t isoprostonae, and between female sex and prostglandin F2α. In addition, we found a positive association between gestational age and levels of prostaglandin E₂ . Furthermore, in the premature group, we found a positive association between the inspired fraction of oxygen and levels of prostaglandin G₂ .

CONCLUSION

We identified and determined lipid peroxidation biomarkers in term and preterm newborn infants' saliva using specific and validated mass spectrometry technology.

Oxidative Stress in Preterm Newborns

Preterm babies are highly susceptible to oxidative stress (OS) due to an imbalance between the oxidant and antioxidant systems. The generation of free radicals (FR) induces oxidative damage to multiple body organs and systems. OS is the main factor responsible for the development of typical premature infant diseases, such as bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis, intraventricular hemorrhage, periventricular leukomalacia, kidney damage, eryptosis, and also respiratory distress syndrome and patent ductus arteriosus. Many biomarkers have been detected to early identify newborns at risk of developing a free radical-mediated disease and to investigate new antioxidant strategies. This review reports the current knowledge on OS in the preterm newborns and the newest findings concerning the use of OS biomarkers as diagnostic tools, as well as in implementing antioxidant therapeutic strategies for the prevention and treatment of these diseases and their sequelae.

Immediate "Kangaroo Mother Care" and Survival of Infants with Low Birth Weight

BACKGROUND

"Kangaroo mother care," a type of newborn care involving skin-to-skin contact with the mother or other caregiver, reduces mortality in infants with low birth weight (<2.0 kg) when initiated after stabilization, but the majority of deaths occur before stabilization. The safety and efficacy of kangaroo mother care initiated soon after birth among infants with low birth weight are uncertain.

METHODS

We conducted a randomized, controlled trial in five hospitals in Ghana, India, Malawi, Nigeria, and Tanzania involving infants with a birth weight between 1.0 and 1.799 kg who were assigned to receive immediate kangaroo mother care (intervention) or conventional care in an incubator or a radiant warmer until their condition stabilized and kangaroo mother care thereafter (control). The primary outcomes were death in the neonatal period (the first 28 days of life) and in the first 72 hours of life.

RESULTS

A total of 3211 infants and their mothers were randomly assigned to the intervention group (1609 infants with their mothers) or the control group (1602 infants with their mothers). The median daily duration of skin-to-skin contact in the neonatal intensive care unit was 16.9 hours (interquartile range, 13.0 to 19.7) in the intervention group and 1.5 hours (interquartile range, 0.3 to 3.3) in the control group. Neonatal death occurred in the first 28 days in 191 infants in the intervention group (12.0%) and in 249 infants in the control group (15.7%) (relative risk of death, 0.75; 95% confidence interval [CI], 0.64 to 0.89; P = 0.001); neonatal death in the first 72 hours of life occurred in 74 infants in the intervention group (4.6%) and in 92 infants in the control group (5.8%) (relative risk of death, 0.77; 95% CI, 0.58 to 1.04; P = 0.09). The trial was stopped early on the recommendation of the data and safety monitoring board owing to the finding of reduced mortality among infants receiving immediate kangaroo mother care.

CONCLUSIONS

Among infants with a birth weight between 1.0 and 1.799 kg, those who received immediate kangaroo mother care had lower mortality at 28 days than those who received conventional care with kangaroo mother care initiated after stabilization; the between-group difference favoring immediate kangaroo mother care at 72 hours was not significant. (Funded by the Bill and Melinda Gates Foundation; Australian New Zealand Clinical Trials Registry number, ACTRN12618001880235; Clinical Trials Registry-India number, CTRI/2018/08/015369.).

End-of-Life Care for Neonates: Assessing and Addressing Pain and Distressing Symptoms

One of the most essential components of end-of-life (EOL) care for neonates is assessing and addressing distressing symptoms. There is limited evidence to guide neonatal EOL symptom management and therefore significant variety in treatment (1-4). EOL neonatal palliative care should include identifying and relieving distressing symptoms. Symptoms to manage at neonatal EOL may include pain using both non-pharmacologic and pharmacologic comfort measures, respiratory distress, secretions, agitation and neurologic symptoms, nutrition and gastrointestinal distress, and skin care. Also of equal importance is communication surrounding familial existential distress and psychosocial care (1, 5-7). Institutions should implement a guideline for neonatal EOL care as guidelines have been shown to decrease variability of interventions and increase use of pharmacologic symptom management (4). Providers should consult with palliative care teams if available for added multidisciplinary support for family and staff, which has been shown to enhance EOL care in neonates (8, 9).

Oxidative Stress in Preterm Infants: Overview of Current Evidence and Future Prospects

Preterm birth (PTB), defined as parturition prior to 37 weeks of gestation, is the leading cause of morbidity and mortality in the neonatal population. The incidence and severity of complications of prematurity increase with decreasing gestational age and birthweight. The aim of this review study is to select the most current evidence on the role of oxidative stress in the onset of preterm complication prevention strategies and treatment options with pre-clinical and clinical trials. We also provide a literature review of primary and secondary studies on the role of oxidative stress in preterm infants and its eventual treatment in prematurity diseases. We conducted a systematic literature search of the Medline (Pubmed), Scholar, and ClinicalTrials.gov databases, retroactively, over a 7-year period. From an initial 777 articles identified, 25 articles were identified that met the inclusion and exclusion criteria. Of these, there were 11 literature reviews: one prospective cohort study, one experimental study, three case-control studies, three pre-clinical trials, and six clinical trials. Several biomarkers were identified as particularly promising, such as the products of the peroxidation of polyunsaturated fatty acids, those of the oxidation of phenylalanine, and the hydroxyl radicals that can attack the DNA chain. Among the most promising drugs, there are those for the prevention of neurological damage, such as melatonin, retinoid lactoferrin, and vitamin E. The microbiome also has an important role in oxidative stress. In conclusion, the most recent studies show that a strong relationship between oxidative stress and prematurity exists and that, unfortunately, there is still little therapeutic evidence reported in the literature.