Evaluation of a new tool - "Step by step with my baby" - to support parental involvement in the care of preterm infants

BACKGROUND AND AIMS

Parental guidance is essential for supporting parental involvement, maintaining the quality and safety of infant care, and limiting parental stress. The efficiency of a new tool to support parental empowerment - "Step by step with my baby" - was evaluated. The perception of this tool by parents and nurses was studied.

METHODS

This was a prospective, observational study conducted from September 2019 to December 2020 at a level-3 neonatal center. A total of 79 newborns (<33 weeks of gestational age or small for gestational age), 84 parents, and 94 nurses were included. The new tool that was evaluated is in the form of a drawing of flowers to be colored according to the parents' ability to care for their newborn. Six domains were explored and given a score (total of 35 points) according to the parents' ability to care for each item: behavior, skin-to-skin contact, carrying, oral and tube feeding, and routine care. The use and relevance of this tool were evaluated by parents and caregivers.

RESULTS

At a mean of 19 days of life, parents required caregiver support regardless of the skill domain (6/35). After 26 days, the mean score increased to 19.4 (p < 0.05). Parents felt autonomous in changing diapers and monitoring temperature but always required help for skin-to-skin contact, carrying, and feeding with or without a tube. The progression was not affected by the presence of siblings, the distance from home, and staying in the parental hospital room. For 67 % of the parents, the tool gave them a better understanding of their newborn and helped them be more confident (69 %) without feeling judged (81 %). These feelings were upheld by nurses.

CONCLUSIONS

This tool was efficient for evaluating parents' autonomy and helped them take ownership of the care provided.

[Towards an ideal environment in neonatology]

The establishment of sensory systems occurs gradually along a transnatal continuum. During premature birth, hospitalization in neonatology, through its atypical sensory stimulations, can disrupt the development of the baby's still immature brain. To promote harmonious development in children, caregivers and parents must learn to take into account their sensory expectations in order to create the most suitable environment possible for their development.

French Neonatal Society issues recommendations on preventing nasal injuries in preterm newborn infants during non-invasive respiratory support

AIM

To issue practical recommendations regarding the optimal care of nasal skin when non-invasive ventilation support is used.

METHODS

We performed a systematic search of PubMed to identify relevant papers published in English or French through December 2019. Different grades of evidence were evaluated.

RESULTS

Forty-eight eligible studies. The incidence in preterm infants was high. The lesions were more frequent for preterm infants born under 30 weeks of gestational age and/or below 1500 g. The lesion was most often located on the skin of the nose but could also be found on the intranasal mucous membranes or elsewhere on the face. Nasal injuries appear early after the beginning of non-invasive ventilation at a mean of 2-3 days for cutaneous lesions and eight or nine for intranasal lesions. The most effective strategies to prevent trauma are the use of a hydrocolloid at the beginning of the support ventilation, the preferential use of a mask and the rotation of ventilation interfaces.

CONCLUSION

Nasal injuries with continuous positive airway pressure treatment in preterm newborn infants were frequent and can induce pain, discomfort and sequelae. The immature skin of preterm newborn infants needs specific attention from trained caregivers and awareness by parents.

Adequacy of sedation analgesia to support the comfort of neonates undergoing therapeutic hypothermia and its impact on short-term neonatal outcomes

Objectives

We aimed to evaluate (1) whether sedation analgesia (SA) used during therapeutic hypothermia (TH) was efficient to support the wellbeing of neonates with hypoxic-ischemic encephalopathy, (2) the SA level and its adjustment to clinical pain scores, and (3) the impact of inadequate SA on short-term neonatal outcomes evaluated at discharge.

Methods

This was an observational retrospective study performed between 2011 and 2018 in two level III centers in Alsace, France. We analyzed the wellbeing of infants by using the COMFORT-Behavior (COMFORT-B) clinical score and SA level during TH, according to which we classified infants into four groups: those with excess SA, adequate SA, lack of SA, and variability of SA. We analyzed the variations in doses of SA and their justification. We also determined the impact of inadequate SA on neonatal outcomes at discharge by multivariate analyses with multinomial regression, with adequate SA as the reference.

Results

A total of 110 patients were included, 89 from Strasbourg university hospital and 21 from Mulhouse hospital. The COMFORT-B score was assessed 95.5% of the time. Lack of SA was mainly found on the first day of TH (15/110, 14%). In all, 62 of 110 (57%) infants were in excess of SA over the entire duration of TH. Most dose variations were related to clinical pain scores. Inadequate SA was associated with negative short-term consequences. Infants with excess of SA had a longer duration of mechanical ventilation [mean ratio 1.46, 95% confidence interval (CI), 1.13-1.89, p = 0.005] and higher incidence of abnormal neurological examination at discharge (odds ratio 2.61, 95% CI, 1.10-6.18, p = 0.029) than infants with adequate SA.

Discussion

Adequate SA was not easy to achieve during TH. Close and regular monitoring of SA level may help achieve adequate SA. Excess of SA can be harmful for newborns with hypoxic-ischemic encephalopathy who are undergoing TH.

Optimising homeothermy in neonates: a systematic review and clinical guidelines from the French Neonatal Society

AIM

Thermal instability is harmful on the newborn infant. We sought to draw up practical guidelines on maintaining homeothermy alongside skin-to-skin contact.

METHODS

A systematic analysis of the literature identified relevant studies between 2000 and 2021 in the PubMed database. Selected publications were evaluated, and their level of evidence were graded, in order to underpin the development of clinical guidelines.

RESULTS

We identified 7 meta-analyses and 64 clinical studies with a focus on newborn infants homeothermy. Skin-to-skin contact is the easiest and most rapidly implementable method to prevent body heat loss. Alongside skin-to-skin contact, monitoring the newborn infant's body temperature with a target of 37.0°C is essential. For newborn infants <32 weeks of gestation, a skullcap and a polyethylene bag should be used in the delivery room or during transport. To limit water loss, inhaled gases humidification and warming is recommended, and preterm infants weighing less than 1600 g should be nursed in a closed, convective incubator. With regard to incubators, there are no clear benefits for single vs. double-wall incubators as well as for air vs. skin servo control.

CONCLUSION

Alongside skin-to-skin contact, a bundle of practical guidelines could improve the maintenance of homeothermy in the newborn infant.

Pain Behavioural Response to Acoustic and Light Environmental Changes in Very Preterm Infants

Noise and high light illumination in the neonatal intensive care unit (NICU) are recognized as stressors that could alter the well-being and development of vulnerable preterm infants. This prospective observational study evaluated the pain behaviours of very preterm infants (VPIs) to sound peaks (SPs) and light levels variations (LLVs) in the NICU. We measured spontaneously occurring SPs and LLVs in the incubators of 26 VPIs over 10 h. Their behavioural responses were analysed through video recordings using the "Douleur Aigue du Nouveau-né" (DAN) scale. We compared the maximum DAN scores before and after environmental stimuli and the percentage of VPIs with a score ≥ 3 according to the type of stimuli. A total of 591 SPs and 278 LLVs were analysed. SPs of 5 to 15 dBA and LLVs significantly increased the maximum DAN scores compared to baseline. The occurrence of DAN scores ≥ 3 increased with both stressors, with a total of 16% of SPs and 8% of LLVs leading to quantifiable pain behaviour. Altogether, this study shows that VPIs are sensitive to SPs and LLVs, with a slighter higher sensitivity to SPs. The mechanisms leading to pain behaviours induced by noise and light changes should be evaluated further in the context of VPIs brain development. Our results provide further arguments to optimize the NICU sensory environment of neonatal units and to adapt it to the expectations and sensory abilities of VPIs.

French neonatal society position paper stresses the importance of an early family-centred approach to discharging preterm infants from hospital

AIM

The families of hospitalised preterm infants risk depression and post-traumatic stress and the preterm infants risk re-hospitalisation. The French neonatal society's aim was to review the literature on how the transition from hospital to home could limit these risks and to produce a position paper.

METHODS

A systematic literature review was performed covering 1 January 2000 to 1 January 2018, and multidisciplinary experts examined the scientific evidence.

RESULTS

We identified 939 English and French papers and 169 are quoted in the position paper. Most studies stressed the importance of early, personalised and progressive involvement of the family. Healthcare staff and families should assess discharge preparations jointly. This evaluation should assess the capacities of the newborn infant, with regard to its physiological maturity. It should also assess the family's ability to supply the medical, psychological and social assistance required before and after discharge. There should be a structured follow-up process that includes effective communication, various tools, interventions, networks, health and social professionals.

CONCLUSION

Discharge preparations may improve the transition from hospital to home and the outcomes for the parents and newborn preterm infant. This early family-centred approach should be structured, coordinated and based on individual needs and circumstances.

Recommendation for hygiene and topical in neonatology from the French Neonatal Society

We sought to establish guidelines for hygiene care in newborns based on a systematic review of the literature and grading of evidence using the Groupe de Réflexion et d'Evaluation de l'Environement des Nouveau-nés (GREEN) methodology. We examined 45 articles and 4 reports from safety agencies. These studies recommend a tub bath (rather than a sponge bath) for full-term infants and a swaddle bath for preterm newborns. They also recommend against daily cleansing of preterm infants. The literature emphasized that hygiene care must consider the clinical state of the newborn, including the level of awareness and behavioral responses. Hospitalized newborns treated with topical agents may also experience high exposure to potentially harmful excipients of interest. Caregivers should therefore be aware of the excipients present in the different products they use. In high-resource countries, the available data do not support the use of protective topical agents for preterm infants.Conclusions: We recommend individualization of hygiene care for newborns. There is increasing concern regarding the safety of excipients in topical agents that are used in neonatology. A multidisciplinary approach should be used to identify an approach that requires lower levels of excipients and alternative excipients. What is known: • Hygiene care is one of the most basic and widespread types of care received by healthy and sick newborns worldwide. • There is no current guideline on hygiene for preterm or hospitalized term newborn. What is new: • The French Group of Reflection and Evaluation of the environment of Newborns (GREEN) provided here guidelines based on the current body of evidence. • Caregivers should be aware of the many issues related to hygiene care of newborns including newborns' behavioral responses to hygiene care, exposition to excipients of interest, and the potential risk of protective topical agents in a preterm infant. provided here guidelines based on the current body of evidence. • Caregivers should be aware of the many issues related to hygiene care of newborns including newborns' possible behavioral responses to hygiene care, exposition to excipients of interest and the potential risk of protective topical agents in a preterm infant.

Observational study found that even small variations in light can wake up very preterm infants in a neonatal intensive care unit

AIM

This prospective observational study evaluated the behavioural responses of very preterm infants to spontaneous light variations.

METHODS

We measured spontaneous light variations in the incubators of 27 very preterm infants, with a median gestational age of 28 weeks (range 26-31 weeks), over 10 hours. All of them had been admitted to the neonatal care unit of the Strasbourg University Hospital, France, between April 2008 and July 2009. Two independent raters examined changes in the infants' behavioural states using video recordings. The percentage of awakenings was recorded when there were light variations and during control periods with no changes.

RESULTS

We analysed 275 periods following light variations and 275 control periods. The overall percentage of awakenings was greater during periods following a change in light than during control periods (16.3% vs 11%, p = 0.03). The extent of light protection affected the percentage of awakenings. In mild light protection, there were more awakenings following changes in light than in control periods (25.6% vs 6.7%, p = 0.01). This difference was not found in high light protection.

CONCLUSION

Very preterm infants can be woken up by small variations in light, when the light protection in their incubator is insufficient.

Very preterm infants can detect small variations in light levels in incubators

AIM

This prospective observational study was designed to improve our understanding of the responses of very preterm infants to light level variations in incubators and to evaluate what determined those reactions.

METHODS

The physiological responses of 27 very preterm infants were analysed following variations in the light level environments of their incubators over 10 hours. Heart and respiratory rates, systemic oxygen saturation and regional cerebral oxygen saturations were recorded using near-infrared spectroscopy, and the variation of each parameter was analysed.

RESULTS

We analysed 332 light level changes. Heart rate increased by 3.8 beats per minute (range -2.6 to 12.6), respiratory rate by six cycles per minute (-1.5 to 26) and regional cerebral oxygen saturation by 1.1% (-0.5% to 3.9%) (p < 0.05 each) when delta lux was over 50. Only respiratory rate decreased significantly, by -8.4 cycles per minute (-28 to -0.4), when delta lux was 50 or lower (p < 0.05). The initial level of illumination altered the very preterm infants' responses, with higher reactivity for higher ambient light levels.

CONCLUSION

Very preterm infants reacted to moderate variations in illumination in their incubator, within recommended ranges of light levels, suggesting that they may detect even small light level variations.

[Practical management of neonatal sepsis risk in term or near-term infants]

Incidence of neonatal early-onset sepsis has dramatically declined in France from 0.65 to 0.23‰ live births in 10 years since national guidelines to detect and treat intrapartum women with group B streptococcus colonization have been adopted. However, neonatal early-onset sepsis continues to be a common healthcare burden. Group B streptococcus (GBS) remains the leading cause of bacterial infection in term or near-term infants. As a result of prevention strategies, approximately 30% of pregnant women and more than 2% of newborns are treated with systemic antibiotics. Concerns have been expressed about the safety of wide use of antibiotics such as antibiotic resistance, emergence of Escherichia coli infections, and long-term side effects due to gut microbiota modifications. New recommendations from the Centers of Disease Control in the United States and from European countries aim at improving GBS detection methods, updating algorithms for GBS intrapartum chemoprophylaxis in pregnant women, defining high-risk newborns more efficiently, and limiting biological evaluation in low-risk newborns.

Moderate acoustic changes can disrupt the sleep of very preterm infants in their incubators

AIM

To evaluate the impact of moderate noise on the sleep of very early preterm infants (VPI).

METHODS

Observational study of 26 VPI of 26-31 weeks' gestation, with prospective measurements of sound pressure level and concomitant video records. Sound peaks were identified and classified according to their signal-to-noise ratio (SNR) above background noise. Prechtl's arousal states during sound peaks were assessed by two observers blinded to the purpose of the study. Changes in sleep/arousal states following sound peaks were compared with spontaneous changes during randomly selected periods without sound peaks.

RESULTS

We identified 598 isolated sound peaks (5 ≤ SNR < 10 decibel slow response A (dBA), n = 518; 10 ≤ SNR < 15 dBA, n = 80) during sleep. Awakenings were observed during 33.8% (95% CI, 24-43.7%) of exposures to sound peaks of 5-10 dBA SNR and 39.7% (95% CI, 26-53.3%) of exposures to sound peaks of SNR 10-15 dBA, but only 11.7% (95% CI, 6.2-17.1%) of control periods. The proportions of awakenings following sound peaks were higher than the proportions of arousals during control periods (p < 0.005).

CONCLUSIONS

Moderate acoustic changes can disrupt the sleep of VPI, and efficient sound abatement measures are needed.

Spontaneous cries can alter the physiological well-being and cerebral oxygenation of very preterm infants

INTRODUCTION

Infant crying is a major expression of distress and can occur without any exogenous stimulation. Little is known, however, about the effects of crying on physiological homeostasis in very preterm infants (VPIs).

METHODS

Environmental, behavioral (video and audio recording) and physiologic (heart rate [HR], respiratory rate [RR], and systemic [SaO(2)] and regional cerebral oxygenation [rSO(2)]) parameters were prospectively evaluated over 10h in 18 VPIs (median gestational age, 28 [27-31] weeks). Only episodes of "spontaneous" and isolated cries were analyzed. Changes in parameters were compared over 5-second periods between baselines and 40s following the onset of crying. Two periods were distinguished: 0-20s (a) and 20-40s (b). Minimal and/or maximal values in these periods were also compared to the baseline.

RESULTS

Of the 18 VPIs initially studied, 13 (72%) presented crying episodes (CE). They experienced 210 "spontaneous" and isolated CE, with a median of 9 [range, 1-63] CEs per child. Physiological values varied significantly from the baseline with mainly a mean decrease in HR of -4.8±5.3 beats/min (b) after an initial mean increase of +2.6±2.0 beats/min (a); a mean decrease in RR of -3.8±4.8 cycles/min (a), followed by a mean increase of +5.6±7.3 cycles/min (b) and mean unidirectional decreases in SaO(2) and rSO(2) (minimal values) of -1.8±2.3% and -2.5±3.0%, respectively.

CONCLUSION

Spontaneous cries can alter the homeostasis of VPIs. Their possible adverse consequences and high occurrence emphasize the need for better prevention and response to them.

Infants born very preterm react to variations of the acoustic environment in their incubator from a minimum signal-to-noise ratio threshold of 5 to 10 dBA

INTRODUCTION

Very early preterm infants (VPIs) are exposed to unpredictable noise in neonatal intensive care units. Their ability to perceive moderate acoustic environmental changes has not been fully investigated.

RESULTS

Physiological values of the 598 isolated sound peaks (SPs) that were 5-10 and 10-15 dB slow-response A (dBA) above background noise levels and that occurred during infants' sleep varied significantly, indicating that VPIs detect them. Exposure to 10-15 dBA SPs during active sleep significantly increased mean heart rate and decreased mean respiratory rate and mean systemic and cerebral oxygen saturations relative to baseline.

DISCUSSION

VPIs are sensitive to changes in their nosocomial acoustic environment, with a minimal signal-to-noise ratio (SNR) threshold of 5-10 dBA. These acoustic changes can alter their well-being.

METHODS

In this observational study, we evaluated their differential auditory sensitivity to sound-pressure level (SPL) increments below 70-75 dBA equivalent continuous level in their incubators. Environmental (SPL and audio recording), physiological, cerebral, and behavioral data were prospectively collected over 10 h in 26 VPIs (GA 28 (26-31) wk). SPs emerging from background noise levels were identified and newborns' arousal states at the time of SPs were determined. Changes in parameters were compared over 5-s periods between baseline and the 40 s following the SPs depending on their SNR thresholds above background noise.

[Sensory system development and the physical environment of infants born very preterm]

The sensory systems develop in several sequences, with a process specific to each system and with a transnatal continuum. This development is based partly on interactions between the fetus and the newborn and their physical and human environments. These interactions are key drivers of the child development. The adaptation of the newborn's environment is crucial for his survival, his well-being and his development, especially if he is born prematurely. The physical environment of the hospital where immature infants are immersed differs greatly from the uterine environment from which they were extracted prematurely. There are discrepancies between their sensory expectations originating in the antenatal period and the atypical stimuli that newborns encounter in their postnatal nosocomial environment. These assertions are valid for all sensory modalities. Many studies have proven that very preterm infants are highly sensitive to this environment which can affect their physiological and behavioural well being. Moreover, it can alter their perception of important human sensory signals, particularly the ones coming from their mother. The long term impacts of this environment are more difficult to identify due to the multi-sensory nature of these stimuli and the multifactorial origin of the neurological disorders that these children may develop. However, the adaptation of their physical environment is one of the corner stones of specific developmental care programs, like the NIDCAP program that has been shown to be successful to improve their short and medium term outcomes. The architectural design, technical equipment and used health-care products, and the strategies and organizations of care are the main determinants of the physical environment of these children. Recommendations for the hospital environment, integrating a newborn's developmental perspective, have been made available. They should be applied more widely and should be completed. Technological equipment advances are also expected to allow better compliance to them. All these evolutions are completely in accordance with the concept of humane neonatal care.