Impact of Skin-to-Skin Parent-Infant Care on Preterm Circulatory Physiology

doi:10.1016/j.jpeds.2020.03.041

The Journal of Pediatrics

Volume 222, July 2020, Pages 91-97.e2

https://doi.org/10.1016/j.jpeds.2020.03.041 Get rights and content

Objectives

To ascertain the impact of skin-to-skin care between parents and infants on cardiac function and cerebral blood flow in preterm infants.

Study design

We undertook a prospective study of 40 self-ventilating preterm infants at a quaternary center and assessed cardiac performance and cerebral blood flow. Assessments were carried out two hours before skin-to-skin care and then 60 minutes after skin-to-skin care (with the infant still on parent and turned supine).

Results

Infants were 30.5 ± 0.6 weeks’ gestational age and 1378 ± 133 g birthweight. Axillary temperature noted a nonsignificant increase during skin-to-skin care from 36.7 ± 0.07°C to 36.9 ± 0.07°C (P = .07). Cardiac contractility (right ventricular fractional area change [26.5% ± 0.3% vs 27.8% ± 0.4; P < .001] and tricuspid annular plane systolic excursion [0.73 ± 0.03 cm vs 0.77 ± 0.03 cm; P = .02]) increased significantly, coincident with decreased measures of pulmonary vascular resistance. An increase in systemic cardiac output was associated with increased cerebral blood flow and reduced middle cerebral artery resistive index (0.81 ± 0.02 vs 0.74 ± 0.02; P = .0001).

Conclusions

We documented a significant circulatory beneficial adaptation to a common neonatal practice. These findings align with previously documented physiologic benefits in cardiorespiratory stability and cardiac rhythm in preterm infants, and may be mediated through modulation of the autonomic nervous system.

Section snippets

Methods

The study was approved by the Health Research Ethics Board (approval number RES-19-0000-553A). Informed written parental consent was obtained. The study was conducted at a quaternary center, caring for infants ≥23 weeks of gestational age onward as well as providing surgery as required. This neonatal intensive care unit with a total bed strength of 64 cots (with one-half providing respiratory support), admits approximately 200 infants <32 weeks of gestational age annually, ∼80 of which have a

Results

Forty infants met the inclusion criteria. The mean gestational age and BW of the study cohort were 30.5 ± 0.6 weeks and 1378 ± 133 g, respectively, and 35 of the 40 caregivers were mothers. Table II depicts demographic details of the cohort. Most of the infants were inborn, and 80% (32/40) were appropriate for gestational age. Thirteen infants (32%) required no respiratory support beyond initial stabilizing continuous positive airway pressure at the time of delivery. Two infants were intubated

Discussion

Important autonomic physiologic modulation in response to skin-to-skin care has been previously demonstrated.³^,¹⁷ The practice of skin-to-skin care in comparison with conventional care (ie, no skin-to-skin care), has shown benefits including improved body temperature and cardiorespiratory stability. Our study on premature infants noted significant improvements in cerebral blood flow and cardiovascular performance with skin-to-skin care. The findings complement previous conclusions of beneficial

References (50)

R. Feldman et al.
Maternal-preterm skin-to skin contact enhances child physiologic organization and cognitive control across the first 10 years of life
Biol Psychiatry
(2014)
J. Milgrom et al.
Early communication in preterm infants following intervention in the NICU
Early Hum Dev
(2013)
A. Sehgal et al.
Cardiac function and arterial biophysical properties in small for gestational age infants: postnatal manifestations of fetal programming
J Pediatr
(2013)
N.P. Heragu et al.
Heart rate variability in healthy children and in those with congenital heart disease both before and after operation
Am J Cardiol
(1999)
M. Zelenko et al.
Heart rate correlates of attachment status in young mothers and their infants
J Am Acad Child Adolesc Psychiatry
(2005)
E.R. de Kloet et al.
Stress, genes and the mechanism of programming the brain for later life
Neurosci Biobehav Rev
(2005)
X. Cong et al.
Kangaroo Care modifies preterm infant heart rate variability in response to heel stick pain: pilot study
Early Human Dev
(2009)
C. Calixto et al.
Correlation between plasma and salivary cortisol levels in preterm infants
J Pediatr
(2002)
N.H. Kalin et al.
Opiate systems in mother and infant primates coordinate intimate contact during reunion
Psychoneuroendocrinology
(1995)
Kangaroo mother care to reduce morbidity and mortality in low-birth-weight infants

A. Conde-Agudelo et al.

Kangaroo mother care to reduce morbidity and mortality in low birthweight infants

Cochrane Database Syst Rev

(2016)

S.M. Ludington-Hoe et al.

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

Neonatal Netw

(2004)

D.R. Kommers et al.

Features of heart rate variability capture regulatory changes during kangaroo care in preterm infants

J Pediatr

(2017)

R. Feldman et al.

Comparison of skin to-skin (kangaroo) and traditional care: parenting outcomes and preterm infant development

Pediatrics

(2002)

S. Ohgi et al.

Comparison of kangaroo care and standard care: behavioural organization, development, and temperament in healthy, low-birth-weight infants through 1 year

J Perinatol

(2002)

A. Sehgal et al.

Preterm growth restriction and bronchopulmonary dysplasia: the vascular hypothesis and related physiology

J Physiol

(2019)

A. Sehgal et al.

Right ventricular function in infants with bronchopulmonary dysplasia: association with respiratory sequelae

Neonatology

(2016)

A. Sehgal et al.

Cardiorespiratory physiology following minimally invasive surfactant therapy in preterm infants

Neonatology

(2019)

A.J.A. Ziino et al.

Effects of Rho-kinase inhibition on pulmonary hypertension, lung growth, and structure in neonatal rats chronically exposed to hypoxia

Pediatr Res

(2010)

A. Sehgal et al.

Cardiac adaptation in asphyxiated infants treated with therapeutic hypothermia

J Neonatal Perinatal Med

(2019)

M. Kluckow et al.

Superior vena cava flow in newborn infants: a novel marker of systemic blood flow

Arch Dis Child Fetal Neonatal

(2000)

A. Sehgal

Suprasternal optical window to Doppler the superior vena cava in neonates

J Echocardiography

(2011)

A.J. Mitchell et al.

Effects of daily kangaroo care on cardiorespiratory parameters in preterm infants

J Neonatal Perinatal Med

(2013)

M. Kluckow et al.

Low superior vena cava flow and intraventricular haemorrhage in preterm infants

Arch Dis Child Fetal Neonatal Ed

(2000)

A.A. Korraa et al.

Impact of kangaroo mother care on cerebral blood flow of preterm infants

Ital J Pediatr

(2014)

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A systematic review of fatherhood and kangaroo care in the NICU
2024, Children and Youth Services Review
Each year millions of fathers face the hospitalization of their premature babies in the NICU. Without having any preparation to accompany the hospitalization of the newborn. Hospitalization in the NICU generates an abrupt separation between the parents and the newborns, complicating the development of attachment between the father-baby dyad; to prevent this, NICU use the KC, a low-cost method that promotes and improves attachment.
This systematic review aimed to identify what the experience of fatherhood is like having a premature baby and performing KC at a NICU.
We searched in the databases APA PsycNet, BVS, Web of Science, PubMed,
Scopus, and The Cochrane Library (The Cochrane Central Register of Controlled.
Trials), with the period from 2010 to October 2023. We followed the criteria from the.
Prisma manual for this systematic review. We use the Critical Appraisal Skills Program.
to assess the studies' quality and the Mendeley software to manage the references.
The searches returned a total of 928 articles and of these 37 were eligible. The results of the articles for the review were synthesized analyzing the theme. The father's experience in the NICU has benefited from the kangaroo method and from the skin-to-skin that strengthens the father-baby attachment.
Conclusions and implications for practice: Support from health professionals is vital to encourage fathers to care for their babies. Fathers' emotions are a mixture of positive feelings such as joy for their child's birth and sadness for the hospitalization. It is essential that the health personnel include fathers, fostering equity between the mother and the father. Hospital policies must ensure the free insertion of the father into the NICU.
The effect of kangaroo mother care or skin-to-skin contact on infant vital signs: A systematic review and meta-analysis
2023, Midwifery
It has been reported that kangaroo mother care/skin-to-skin contact immediately after birth facilitates the newborn's physiological and psychological adaptation to extrauterine life.
To examine the effect of kangaroo mother care/skin-to-skin contact on infants’ body temperature, oxygen saturation, respiratory rate and heart rate.
Systematic review and meta-analysis.
PubMed, ScienceDirect, SpringerLink, Wiley Online Library and Taylor & Francis Online were searched for the period 1 January 2015 to 30 November 2021 for studies published in the English language. The methodological quality of articles was assessed using the modified Jadad scale and the Newcastle–Ottawa scale. Effect size calculations were made using the fixed effects and random effects models.
This meta-analysis included 13 studies, with a total of 891 infants. Kangaroo mother care/skin-to-skin contact was effective for maintaining infants’ body temperature (p = 0.000). Infants’ heart rate decreased (p = 0.015) and oxygen saturation was higher (p = 0.040) following kangaroo mother care/skin-to-skin contact. Kangaroo mother care/skin-to-skin contact did not affect infants’ respiratory rate (p = 0.896), but infants’ respiratory rate decreased after kangaroo mother care/skin-to-skin contact (p = 0.047).
Kangaroo mother care/skin-to-skin contact is effective for improving the vital signs of newborns. Kangaroo mother care/skin-to-skin contact is recommended for all neonates, and standardization of this approach would be beneficial.
The Swedish approach to nurturing extremely preterm infants and their families: A nursing perspective
2022, Seminars in Perinatology
Citation Excerpt :
SSC promotes optimal brain development in preterm infants, facilitates supportive positioning, and parent–infant bonding.5 Although data is somewhat more limited in extremely preterm infants, it is reasonable to assume that the many benefits of SSC6,7 can be applied also to this group. Early initiation of SSC has been shown to increase the time parents spend in the NICU as well as the duration of SSC.8,9
Nurturing extremely premature infants is a complicated task that not only necessitates a systematic approach to the immature physiology and its medical management, but also to the needs of the family. Infants born at 22-24 weeks require many weeks of intensive care including a long duration of mechanical ventilation, numerous stressful medical interventions, and for the parents to spend a lot of time in the Neonatal Intensive Care unit (NICU). This paper aims to outline the Swedish nursing approach to nurturing these infants and their families. The nursing care is structured so the parents are the primary caregivers supported by the staff and is based on: timely expression and provision of mother's own breast milk, early and prolonged skin-to-skin contact and close collaboration with the family. While this presentation is based on a single-center's experience, it well represents the general features of nursing provided to extremely preterm infants in Swedish NICUs.
Preterm infant heart rate is lowered after Family Nurture Intervention in the NICU: Evidence in support of autonomic conditioning
2021, Early Human Development
Citation Excerpt :
Neu et al. [23] provided a compelling argument for the practice of SSC. The authors found in a prospective cohort study that SSC significantly improved cardiac function in preterm infants, and concluded that SSC between parents and newborn infants was a powerful influence with multiple mediators affecting the ANS and physiologic regulation and adaptation [17,33]. Recently, in a sample of 11 preterm infants, Kommers et al. reported reductions in HRV during SSC that were associated with a decrease in the extent of transient HR decelerations [1].
Cardiac complications after premature birth are associated with negative long-term consequences to health. The Family Nurture Intervention (FNI) has been designed to support mother-infant parasympathetic calming sessions in the neonatal intensive care unit (NICU). FNI has shown neurodevelopmental and autonomic benefit across infant development.
We tested the hypothesis that heart rate (HR) will decrease after FNI over the course of the NICU stay, compared to matched controls.
We used a case-matched design. The intervention included on average four ~1-hour facilitated mother-infant ‘calming’ sessions per week. We collected 24/7 real time heart rate data from a central monitoring system and analyzed data from two time-periods.
The intervention group comprised 37 infants born ~30 weeks gestational age (GA) in a level IV NICU, treated with FNI. From the same NICU and time-period, we created a contemporaneous comparison group of 32 infants who were case-matched to each intervention infant for sex, age-at-birth, singleton or twin status, month of admission and length of stay.
Using generalized estimating equation (GEE) modeling, we analyzed 24/7 HR data during a 1-hour period between 4:30 and 5:30 am each day in the NICU, when all infants were least disturbed. Using repeated measures ANOVA, we analyzed 24/7 HR data during a 6-week period starting 1 week prior to the start of FNI and ending 5 weeks after start.
GEE modeling of the 1-hour data from all subjects showed significant lower HR in the FNI group, compared with controls. ANOVA modeling on a subset of subjects over the five-week period showed that FNI infant HR decreased in a dose-response manner relative to SC HR.
This study suggests FNI may condition lower infant HR in a dose-response manner during the NICU stay.
Attachment between father and premature baby in kangaroo care in a neonatal unit of a public hospital
2021, Journal of Neonatal Nursing
Citation Excerpt :
Research has shown that skin-to-skin contact has positive health benefits for the premature baby and the father. After the first hour of skin-to-skin contact, cortisol levels, and blood pressure in the fathers decreased; in babies, it can generate cardiorespiratory stability, increase oxytocin levels, producing positive neurodevelopmental and neurobiological results (Hardin et al., 2020; Sehgal et al., 2020). Performing skin-to-skin contact promotes the interaction between father and son, favors establishing the relationship between these two, increasing their attachment (Chen et al., 2017; Kim et al., 2017; Helth et al., 2013).
Prematurity rates are on the rise; every year, thousands of parents face having their babies prematurely. Preterm labor breaks the nature of the attachment between the parents and the baby. The kangaroo method favors interaction and helps to establish attachment between the father-baby dyad. The father often does not have the same opportunities as the mother to participate in the baby's care while staying in the neonatal units.
Analyze fathers' attachment with their babies in a neonatal kangaroo unit.
We conducted a cross-sectional study with 32 fathers of premature babies hospitalized in a neonatal unit. We use the paternal postnatal attachment scale. It is an instrument that measures attachment in three factors: patience, tolerance, and satisfaction; Pride and affection; interaction and transition to parenthood.
Attachment was affected by factors such as the type of prematurity of the baby, the residence of the father, the type of birth, and the fathers who made skin-to-skin contact. There were no significant differences in attachment scores for the father's age, the baby's gender, or the father's education level.
Fathers who performed skin-to-skin contact have higher attachment scores. Fathers are in a complicated situation as they do not have a paternity leave equivalent to that of mothers, and by the economic burden of having a premature baby.
Effects of skin-to-skin care on electrical activity of the diaphragm in preterm infants during neurally adjusted ventilatory assist
2021, Early Human Development
Citation Excerpt :
Doxapram treatment was not administered to the infants included in the study. The median NAVA level was 1.2 cmH2O/μV (1, 1.4) and the median positive end-expiratory pressure was 6 cmH2O [5,6]. Supplemental oxygen during SSC was provided in 17 (50%) procedures.
Skin-to-skin care (SSC) reduces neonatal mortality and morbidity and is widely implemented in the neonatal intensive care unit. However, changes in respiratory effort during SSC in ventilated preterm infants remain unclear.
To evaluate the effect of SSC on electrical activity of the diaphragm (Edi) and vital signs in premature infants who are intubated and under neurally adjusted ventilatory assist ventilation.
We performed an observational cross-over study. Data were measured in three periods: before (pre-SSC period), during (SSC period), and after (post-SSC period) SSC. Stable 30-min data in each period were extracted.
Thirty-four SSC procedures were performed in 14 preterm infants with a median gestational age of 25.3 weeks (interquartile range, 24, 26.4) and a birth weight of 659 g (566, 694). The median postnatal age was 41 days (31, 53) at the study with a median postmenstrual age of 31.3 weeks (30.4, 32.5).
Median values of Edi peak, Edi minimum, respiratory rate, SpO₂, and heart rate were measured in each condition. The Kruskal–Wallis test with Bonferroni multiple comparisons was used to compare each parameter in each period.
Median Edi peak and Edi minimum values were significantly lower during SSC compared with pre- and post-SSC, without any change in respiratory rate, SpO₂, or heart rate.
Respiratory efforts as evaluated by Edi are significantly reduced during SSC in ventilated preterm infants.

View all citing articles on Scopus

: The authors declare no conflicts of interest.

^∗: Emeritus.

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Original ArticlesImpact of Skin-to-Skin Parent-Infant Care on Preterm Circulatory Physiology

Objectives

Study design

Results

Conclusions

Section snippets

Methods

Results

Discussion

Biol Psychiatry

Early Hum Dev

J Pediatr

Am J Cardiol

J Am Acad Child Adolesc Psychiatry

Neurosci Biobehav Rev

Early Human Dev

J Pediatr

Psychoneuroendocrinology

Kangaroo mother care to reduce morbidity and mortality in low-birth-weight infants

Kangaroo mother care to reduce morbidity and mortality in low birthweight infants

Cochrane Database Syst Rev

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

Neonatal Netw

Features of heart rate variability capture regulatory changes during kangaroo care in preterm infants

J Pediatr

Comparison of skin to-skin (kangaroo) and traditional care: parenting outcomes and preterm infant development

Pediatrics

Comparison of kangaroo care and standard care: behavioural organization, development, and temperament in healthy, low-birth-weight infants through 1 year

J Perinatol

Preterm growth restriction and bronchopulmonary dysplasia: the vascular hypothesis and related physiology

J Physiol

Right ventricular function in infants with bronchopulmonary dysplasia: association with respiratory sequelae

Neonatology

Cardiorespiratory physiology following minimally invasive surfactant therapy in preterm infants

Neonatology

Effects of Rho-kinase inhibition on pulmonary hypertension, lung growth, and structure in neonatal rats chronically exposed to hypoxia

Pediatr Res

Cardiac adaptation in asphyxiated infants treated with therapeutic hypothermia

J Neonatal Perinatal Med

Superior vena cava flow in newborn infants: a novel marker of systemic blood flow

Arch Dis Child Fetal Neonatal

Suprasternal optical window to Doppler the superior vena cava in neonates

J Echocardiography

Effects of daily kangaroo care on cardiorespiratory parameters in preterm infants

J Neonatal Perinatal Med

Low superior vena cava flow and intraventricular haemorrhage in preterm infants

Arch Dis Child Fetal Neonatal Ed

Impact of kangaroo mother care on cerebral blood flow of preterm infants

Ital J Pediatr

Original Articles
Impact of Skin-to-Skin Parent-Infant Care on Preterm Circulatory Physiology