Susan M. Ludington-Hoe

Skin-to-skin Contact (kangaroo Care) Analgesia for Preterm Infant Heel Stick

The purpose of the study was to compare a heel stick conducted during Kangaroo Care (skin-to-skin contact) with the mother to a heel stick in a warmer in reducing premature infant physiologic and behavioral pain responses. Twenty-four premature infants in a university-based neonatal intensive care unit were recruited and randomized to 2 sequences: sequence A group received 3 hours of Kangaroo Care (with a heel stick in Kangaroo Care) followed by 3 hours in a warmer (with a heel stick in the warmer). Sequence B group had warmer care and a heel stick (in the warmer) before Kangaroo Care and a heel stick (in Kangaroo Care). Heart rate, respiratory rate, oxygen saturation, crying time, and behavioral state were measured before, during, and after heel stick. Repeated measures ANOVA and Mann Whitney U statistics were performed. Heart rate and length of crying in response to pain were significantly reduced during Kangaroo Care and the Kangaroo Care heel stick as compared to when infants were in the warmer and had a heel stick in the warmer. Three infants did not cry at all during the Kangaroo Care heel stick; infants slept more during Kangaroo Care than in the warmer. Kangaroo Care positioning before and during heel stick is a simple and inexpensive analgesic intervention to ameliorate pain in stable premature infants.

Neurophysiologic Assessment of Neonatal Sleep Organization: Preliminary Results of a Randomized, Controlled Trial of Skin Contact With Preterm Infants

BACKGROUND. Sleep is important to brain organization, but few strategies to promote sleep among premature infants have been tested. Behaviorally based measures of sleep have shown increased quiet sleep (QS) and decreased active sleep (AS) during skin-to-skin contact (SSC) with the mother, but these results have not been confirmed with objective electroencephalographic/polysomnographic measures of sleep organization. Important differences exist between behavioral and electroencephalographic/polysomnographic definitions of sleep state. METHODS. Data for the first 28 relatively healthy, preterm subjects of an ongoing randomized trial of one 2- to 3-hour session of SSC or incubator care between feedings are reported here. Infants were positioned prone, inclined, and nested in an incubator during the 2- to 3-hour pretest period, were fed, and then went into the test period of SSC or incubator care. Infants were left largely undisturbed throughout testing. A mixed-model regression analysis compared the test-pretest differences in outcome measures within and between groups. RESULTS. Results showed that arousals were significantly lower in the SSC group, compared with the control group, for the entire study period and for test-pretest matched segments of QS and AS. Rapid eye movement was significantly lower for the SSC group for the study period and AS segments. Indeterminate sleep was significantly lower for the SSC group when confounding environmental variables were included in the regression analysis. When 4 subjects who experienced excessive ambient light levels during SSC were removed from analysis, QS increased during SSC. CONCLUSIONS. The patterns demonstrated by the SSC group are analogous to more-mature sleep organization. SSC may be used as an intervention to improve sleep organization in this population of preterm infants.

Randomized controlled trial of kangaroo care: cardiorespiratory and thermal effects on healthy preterm infants.

Purpose: To determine the safety and effects on healthy preterm infants of three continuous hours of kangaroo care (KC) compared to standard NICU care by measuring cardiorespiratory and thermal responses. Design: Randomized controlled trial—pretest-test-posttest control group design. Sample: Twenty-four healthy preterm infants (33–35 weeks gestation at birth) nearing discharge. Eleven of the infants received KC; 13 received standard NICU care. Main Outcome Variables: Heart rate, respiratory rate, oxygen saturation, and abdominal skin temperature were manually recorded every minute. Apnea, bradycardia, periodic breathing, and regular breathing were captured continuously on a pneumocardiogram printout. Three consecutive interfeeding intervals (three hours each) on one day constituted the pretest, test, and posttest periods. Results: Mean cardiorespiratory and temperature outcomes remained within clinically acceptable ranges during KC. Apnea, bradycardia, and periodic breathing were absent during KC. Regular breathing increased for infants receiving KC compared to infants receiving standard NICU care.

Kangaroo Care modifies preterm infant heart rate variability in response to heel stick pain: Pilot study

BACKGROUND Heel stick is the most common painful procedure for preterm infants in neonatal intensive care units. Resultant pain causes adverse physiological effects in major organ systems. Kangaroo Care (KC), involving mother-infant skin-to-skin contact is a promising analgesic for infant pain; however, the effect of KC on the autonomic nervous systems response to pain is unknown. AIM To determine if KC results in improved balance in autonomic responses to heel stick pain than the standard method where infants remain in an incubator care (IC) for the heel stick. STUDY DESIGN A randomized cross-over trial. SUBJECTS Fourteen preterm infants, 30-32 weeks gestational age and less than 9 days postnatal age. OUTCOME MEASURES Infant behavioral state, heart rate, heart rate variability (HRV) indices including low frequency (LF) and high frequency (HF) power, and the LF/HF ratio measured over Baseline, Heel Warming, Heel Stick, and Recovery periods in KC and IC conditions. RESULTS HRV differences between KC and IC were that LF was higher in KC at Baseline (p<.01) and at Heel Stick (p<.001), and HF was higher in KC at Baseline than in the IC condition (p<.05). The LF/HF ratio had less fluctuation across the periods in KC than in IC condition and was significantly lower during Recovery in KC than in IC (p<.001). CONCLUSIONS Infants experienced better balance in response in KC than IC condition as shown by more autonomic stability during heel stick. KC may be helpful in mediating physiologic response to painful procedures in preterm infants.

Neurophysiologic assessment of brain maturation after an 8-week trial of skin-to-skin contact on preterm infants

OBJECTIVE Skin-to-skin contact (SSC) promotes physiological stability and interaction between parents and infants. Analyses of EEG-sleep studies can compare functional brain maturation between SSC and non-SSC cohorts. METHODS Sixteen EEG-sleep studies were performed on eight preterm infants who received 8 weeks of SSC, and compared with two non-SSC cohorts at term (N=126), a preterm group corrected to term age and a full-term group. Seven linear and two complexity measures were compared (Mann-Whitney U test comparisons p<.05). RESULTS Fewer REMs, more quiet sleep, increased respiratory regularity, longer cycles, and less spectral beta were noted for SSC preterm infants compared with both control cohorts. Fewer REMs, greater arousals and more quiet sleep were noted for SSC infants compared with the non-SSC preterms at term. Three right hemispheric regions had greater complexity in the SSC group. Discriminant analysis showed that the SSC cohort was closer to the non-SSC full-term cohort. CONCLUSIONS Skin-to-skin contact accelerates brain maturation in healthy preterm infants compared with two groups without SSC. SIGNIFICANCE Combined use of linear and complexity analysis strategies offer complementary information regarding altered neuronal functions after developmental care interventions. Such analyses may be helpful to assess other neuroprotection strategies.

Safe criteria and procedure for kangaroo care with intubated preterm infants.

Kangaroo care (KC) was safely conducted with mechanically ventilated infants who weighed less than 600 grams and were less than 26 weeks gestation at birth. These infants, ventilated for at least 24 hours at the time of the first KC session, were considered stable on the ventilator at low settings (intermittent mandatory ventilation < 35 breaths per minute and FiO2 < 50%), had stable vital signs, and were not on vasopressors. A protocol for implementation of KC with ventilated infants that uses a standing transfer, with two staff members assisting to minimize the possibility of extubation, is presented. Also discussed is the positioning of the ventilator tubing during KC. This protocol was implemented without any accidental extubation throughout an experimental research study. The criteria and protocol were compared to those available in published reports and revealed many similar elements, providing additional support for the recommended protocol. No adverse events occurred with the criteria and protocol reported here, suggesting that they can be adopted for broader use.

Randomized Crossover Trial of Kangaroo Care to Reduce Biobehavioral Pain Responses in Preterm Infants: A Pilot Study

Kangaroo care (KC), skin-to-skin contact between mother and infant, is a promising method for blunting pain responses. This crossover pilot tested KC effects on biobehavioral responses to heel stick in preterm infants (30—32 weeks’ gestational age, 2—9 days old) measured by Premature Infant Pain Profile (PIPP) and salivary and serum cortisol. Mother—infant dyads were randomly assigned to KC heel stick (KCH) first or incubator heel stick (IH) first. Study 1 (80-min study, N = 18) tested the effect of 80 min of KC before and throughout the heel stick procedure versus incubator care. Study 2 (30-min study, N = 10) tested 30 min of KC before and throughout the heel stick versus incubator care. KCH and IH began during a premeasurement phase and continued through four data collection phases: baseline, heel warming, heel stick, and recovery. PIPP responses were measured every 30 s during data collection; salivary cortisol was measured at the end of baseline and recovery; and serum cortisol was measured during heel stick. Study 1 showed no differences between KCH and IH. Study 2 showed lower PIPP scores at four time points during recovery (p < .05 to p < .001), lower salivary cortisol at the end of recovery (p < .05), and lower serum cortisol during heel stick for the KCH condition (p < .05) as well as clinically lower PIPP scores in the KCH condition during heel stick. Thirty minutes of KC before and throughout the heel stick reduced biobehavioral responses to pain in preterm infants.

Infant crying: nature, physiologic consequences, and select interventions.

This article describes the nature of infant crying, the physiologic events and changes associated with it, and appropriate nursing interventions for infant crying. A cry is a series of four movements that basically resembles a Valsalva maneuver. Documented immediate and long-term sequelae of crying include increased heart rate and blood pressure, reduced oxygen level, elevated cerebral blood pressure, initiation of the stress response, depleted energy reserves and oxygen, interrupted mother-infant interaction, brain injury, and cardiac dysfunction. Caregivers are encouraged to answer infant cries swiftly, consistently, and comprehensively. Kangaroo care is an efficient method for preventing, minimizing, and halting crying. Other interventions for crying include swaddled holding, a pacifier, sugar water, a sweet-tasting nonsucrose solution, heartbeat sounds, distraction by lullabies or mother’s voice, rhythmic movement, and reduction of external stimuli.

Kangaroo care at birth for full term infants: a pilot study.

PurposeTo determine whether breastfeeding behaviors, skin temperature, and blood glucose values could be influenced through the use of kangaroo care at the time of birth in healthy full term infants. MethodDescriptive study with nine full term neonates given kangaroo care beginning within 1 minute of birth and continuing until completion of the first breastfeeding by mothers who intended to breastfeed. Infant skin temperature was taken at 1 and 5 minutes after birth and every 15 minutes thereafter. Blood glucose level was taken 60 minutes after birth, the time at which the infant latched onto the breast was recorded, and breastfeeding behaviors were observed during the first breastfeeding. ResultsSkin temperature rose during birth kangaroo care in eight of the nine infants, and temperature remained within neutral thermal zone for all infants. Blood glucose levels varied between 43 and 85 mg/dL for infants who had not already fed and between 43 and 118 mg/dL for those who had fed. All but one infant spontaneously crawled to and latched onto a breast by 74 minutes after birth. Physicians noted that mothers were distracted from episiotomy or laceration repair discomfort during birth kangaroo care. Clinical ImplicationsIn this institution, birth kangaroo care was integrated into routine delivery room care, with nurses noting no change in nursing workload. Nurses have noted observing the crawling, latching, and successful breastfeeding of most infants. Because of the results of this pilot study, birth kangaroo care has been implemented successfully with all women who wish to participate.

An analysis of the kangaroo care intervention using neonatal EEG complexity: A preliminary study

OBJECTIVE Skin-to-skin contact (SSC) promotes physiological stability and interaction between parents and infants. Temporal analyses of predictability in EEG-sleep time series can elucidate functional brain maturation between SSC and non-SSC cohorts at similar post-menstrual ages (PMAs). METHODS Sixteen EEG-sleep studies were performed on eight preterm infants who received 8 weeks of SSC, and compared with two non-SSC cohorts at term (N=126) that include a preterm group corrected to term age and a full term group. Two time series measures of predictability were used for comparisons. RESULTS The SSC premature neonate group had increased complexity when compared to the non-SSC premature neonate group at the same PMA. Discriminant analysis shows that SSC neonates at 40 weeks PMA are closer to the full term neonate non-SSC group than to the premature non-SSC group at the same PMA; suggesting that the KC intervention accelerates neurophysiological maturation of premature neonates. CONCLUSIONS Based on the hypothesis that EEG-derived complexity increases with neurophysiological maturation as supported by previously published research, SSC accelerates brain maturation in healthy preterm infants as quantified by time series measures of predictability when compared to a similar non-SSC group. SIGNIFICANCE Times series methods that quantify predictability of EEG sleep in neonates can provide useful information about altered neural development after developmental care interventions such as SSC. Analyses of this type may be helpful in assessing other neuroprotection strategies.