Neonatal nurses' beliefs about almost continuous parent-infant skin-to-skin contact in neonatal intensive care.

AIMS AND OBJECTIVES: To describe what nurses believe about almost continuous skin-to-skin contact for preterm infants between 32(0) -36(0)  weeks gestation. BACKGROUND: Skin-to-skin contact a few hours per day has become standard care for preterm infants in most high-technology neonatal intensive care units. However, few units practice Kangaroo Mother Care which involves almost continuous skin-to-skin contact. DESIGN: A qualitative descriptive design. METHODS: An online questionnaire with open-ended questions was administered to 129 nurses at three neonatal units. Data were analysed with qualitative content analysis. FINDINGS: Nurses believed they would lose control because of limited access to the infant and would not be able to provide adequate care. Nurses also believed that mothers practicing almost continuous skin-to-skin contact would feel trapped and would experience stress if they could not meet the demands of the method. CONCLUSIONS: Although the nurses can describe several of the documented benefits of almost continuous skin-to-skin contact, an underuse continues to exist. RELEVANCE FOR CLINICAL PRACTICE: Beliefs described by the nurses are important to consider and resolve if the goal is to implement and provide Kangaroo Mother Care.

Effects on postoperative salivary cortisol of relaxation/music and patient teaching about pain management.

The physiological and psychological stress of surgery and postoperative pain can leave patients more susceptible to infection and complications. The present study was designed to determine whether two interventions, patient teaching (PT) for pain management and relaxation/music (RM), reduced cortisol levels, an indicator of stress, following abdominal surgery. Patients (18-75 years) were randomly assigned to receive PT, RM, a combination of the two, or usual care; the 205 patients with both pre- and posttest cortisol values were analyzed. A 2 × 2 factorial design was used to compare groups for PT effects and RM effects. Stress was measured by salivary cortisol before and after 20-min tests of the interventions in the morning and afternoon of postoperative Day 2. Saliva was stimulated with lemon juice and analyzed with high-sensitivity salivary cortisol enzyme immunoassay. Comparisons using analysis of covariance (ANCOVA), controlling for baseline levels, showed no PT effect or RM effect on cortisol in the morning or afternoon. Post hoc ANCOVA showed no significant effects when intervention groups were compared to the control group. Although in previous studies, RM reduced pain and music reduced cortisol on Day 1, in the present study the cortisol response to surgery was not attenuated by PT or RM on Day 2. The RM intervention can be used for pain but needs to be further tested for effects on plasma cortisol in abdominal surgery patients on their first postoperative day.

Supplementing relaxation and music for pain after surgery.

BACKGROUND: Most postoperative patients have unrelieved pain despite the use of patient-controlled analgesia. Nurses need additional effective modalities. Relaxation and music (RM), in addition to analgesics, have been shown to reduce pain more than do analgesics alone. OBJECTIVES: The objectives of the study were to test an intervention of patient teaching for pain management (PT) and compare it with RM for immediate and general effects on postoperative pain. METHODS: Patients having abdominal surgery and receiving patient-controlled analgesia aged 18-75 years (n = 517) were randomized to four groups: PT, RM, a combination (PTRM), and a control. A 2 x 2 factorial design was used to assess PT-Effects and RM-Effects. Immediate effects on pain were measured on visual analogue sensation and distress scales before and after five 20-min tests in the first 2 days. Because participants also listened independently, general nonimmediate effects were examined at eight other times. RESULTS: Using multivariate analysis of covariance with contrasts and pretest control, immediate RM-Effects on pain were found at Day 1 a.m. (p < .001), Day 1 p.m. (p = .04), and Day 2 a.m. (p = .04). No PT-Effects or nonimmediate RM-Effects were found. DISCUSSION: Patient teaching did not result in less pain and did not support the theoretical proposition that PT reduces pain. However, the immediate RM-Effects supported the proposition that nonpharmacological adjuvants to analgesics can ease pain without adding side effects.

Effect of early skin-to-skin contact on mother-preterm infant interaction through 18 months: randomized controlled trial.

BACKGROUND: Preterm birth often negatively influences mother-infant interaction. Skin-to-skin contact postbirth has positive effects on maternal feelings toward their preterm infants and on infant development and family interaction. However, little is known about the long-term effects of skin-to-skin contact on mother-late preterm infant interaction when skin-to-skin contact was experienced early postbirth and intermittently throughout the next five days. OBJECTIVE: The purpose of this report was to examine the effect of skin-to-skin contact on mother-late preterm infant interaction through 18 months. DESIGN: Randomized controlled trial with follow-up. SETTING: Two hospitals in the United States of America. PARTICIPANTS: 100 mothers and their late preterm infants, 32 to <37 weeks' gestation, were recruited. Mother-preterm infant interactions were assessed in 69, 70, and 76 dyads at 6, 12, and 18 months. METHODS: Mothers and their preterm infants were videotaped during a feeding session at 6 and 12 months, and a teaching session at 6, 12, and 18 months. Their interactions were then scored using the Nursing Child Assessment Satellite Feeding Scale and Teaching Scale. RESULTS: Skin-to-skin contact and control dyads had comparable feeding scores at 6 and 12 months. Skin-to-skin contact infants had lower infant teaching scores at six months, a difference that disappeared thereafter. CONCLUSIONS: These inconclusive results call for additional studies with larger doses of skin-to-skin contact, larger sample sizes, and other outcome measures of mother-late preterm infant interactions. Such measures include the Parent-Child Early Relational Assessment and behavioral coding during play.

Skin-to-skin contact for culturally diverse women having breastfeeding difficulties during early postpartum.

BACKGROUND: Early breastfeeding (BF) cessation is more common in black women and women who experience BF difficulties during early postpartum. Skin-to-skin contact (SSC) during early postpartum promotes and sustains BF. The focus of this secondary analysis is on BF status and maternal race/ethnicity. METHODS: Data were collected in a prospective exploratory study with 48 healthy and culturally diverse mother-full-term infant dyads. These dyads were selected because they were experiencing BF difficulties postbirth (mean, 16.9 hours). Following informed consent, the SSC intervention was given with four BFs: the next three after enrollment plus one before hospital discharge. BF status (duration and exclusivity) was measured using a six-category instrument, the Index of Breastfeeding Status, at hospital discharge and by telephone interview 1 week and 1 month later. RESULTS: BF status was generally similar in this culturally diverse sample, except that at 1 month black mothers had lower exclusive BF (33%) and higher BF cessation (46.7%). These mothers were all high risk for poor BF outcomes, with black mothers at highest risk. Even so, BF outcomes exceeded those in studies that included all BF mothers whether or not they were having difficulties. CONCLUSIONS: Based on these findings, we propose that this SSC BF intervention, provided in hospital in a time-sensitive manner by a warm perceptive person, can transcend the likelihood of early BF cessation for most mothers regardless of race/ethnicity.

Kangaroo care and breastfeeding of mother-preterm infant dyads 0-18 months: a randomized, controlled trial.

PURPOSE: To determine the effects of kangaroo care (KC) (skin-to-skin contact) on breastfeeding status in mother-preterm infant dyads from postpartum through 18 months. DESIGN: Randomized, controlled trial. The control group received standard nursery care; in the intervention group, unlimited KC was encouraged. SAMPLE: A subsample of 66 mothers and their preterm infants (32-36 completed weeks gestation, 1,300-3,000 g, 5 minute Apgar > or = 6) who intended to breastfeed. MAIN OUTCOME VARIABLES: Breastfeeding status at hospital discharge and at 1.5, 3, 6, 12, and 18 months as measured by the Index of Breastfeeding Status. RESULTS: KC dyads, compared to control dyads, breastfed significantly longer (5.08 months vs 2.05 months), p = .003. KC dyads also breastfed more exclusively at each measurement, p = .047. More KC dyads than control dyads breastfed at full exclusivity (100 percent breast milk, index of breastfeeding status levels 1 or 2) at discharge and at 1.5, 3, and 6 months. Mean KC contact per day was 4.47 hours.

Randomized controlled trial of very early mother-infant skin-to-skin contact and breastfeeding status.

This study was done to evaluate effects of maternal-infant skin-to-skin contact during the first 2 hours postbirth compared to standard care (holding the infant swaddled in blankets) on breastfeeding outcomes through 1 month follow-up. Healthy primiparous mother-infant dyads were randomly assigned by computerized minimization to skin-to-skin contact (n = 10) or standard care (n = 10). The Infant Breastfeeding Assessment Tool was used to measure success of first breastfeeding and time to effective breastfeeding (time of the first of three consecutive scores of 10-12). Intervention dyads experienced a mean of 1.66 hours of skin-to-skin contact. These infants, compared to swaddled infants, had higher mean sucking competency during the first breastfeeding (8.7 +/- 2.1 vs 6.3 +/- 2.6; P < .02) and achieved effective breastfeeding sooner (935 +/- 721 minutes vs 1737 +/- 1001; P < .04). No significant differences were found in number of breastfeeding problems encountered during follow-up (30.9 +/- 5.51 vs 32.7 +/- 5.84; P < .25) or in breastfeeding exclusivity (1.50 +/- 1.1 vs 2.10 +/- 2.2; P < .45). Sucking competency was also related to maternal nipple protractility (r = .48; P < .03). Very early skin-to-skin contact enhanced breastfeeding success during the early postpartum period. No significant differences were found at 1 month.

Interruptions to breastfeeding dyads on postpartum day 1 in a university hospital.

OBJECTIVE: To describe interruptions (door openings and telephone calls) to breastfeeding dyads on postpartum day 1. DESIGN: A descriptive design of continuous observations of persons entering the mother's room plus record of phone calls from 8 a.m. to 8 p.m. on postpartum day 1. SETTING: Single bedded postpartum rooms in a tertiary level university hospital in northern Midwest United States. PARTICIPANTS: Twenty-nine healthy mother-infant dyads of singleton birth who intended to breastfeed. OUTCOME MEASURES: Frequency and duration of interruptions, number of episodes and duration of time alone, frequency and duration of breastfeeding sessions, and maternal perceptions of the day's activities and time with her newborn. RESULTS: Recorded interruptions totaled 1,555, yielding a mean of 54 interruptions each averaging 17 minutes in length. Half of the 24 episodes of time alone per dyad were less than or equal to 9 minutes; most commonly only 1 minute long. All mothers breastfed 2 to 10 times with an average duration of 20 minutes. CONCLUSION: Many interruptions occurred and were perceived to negatively influence breastfeeding.

Newborn temperature during skin-to-skin breastfeeding in couples having breastfeeding difficulties.

BACKGROUND: Kangaroo (skin-to-skin contact) care facilitates the maintenance of safe temperatures in newborn infants. Concern persists that infants will become cold while breastfeeding, however, especially if in skin-to-skin contact with the mother. This concern might be especially realistic for infants experiencing breastfeeding difficulties. The objective was to measure temperature during a study of mothers and infants who were having breastfeeding difficulties during early postpartum and were given opportunities to experience skin-to-skin contact during breastfeeding. METHOD: Forty-eight full-term infants were investigated using a pretest-test-posttest study design. Temporal artery temperature was measured before, after, and once during 3 consecutive skin-to-skin breastfeeding interventions and 1 intervention 24 hours after the first intervention. RESULTS: During skin-to-skin contact, most infants reached and maintained temperatures between 36.5 and 37.6 degrees C, the thermoneutral range, with only rare exceptions. CONCLUSIONS: The temperatures of study infants reached and remained at the thermoneutral range during breastfeeding in skin-to-skin contact. The data suggest that mothers may have the ability to modulate their infant's temperature during skin-to-skin contact if given the opportunity. Hospital staff and parents can be reassured that, with respect to their temperature, healthy newborn infants, with or without breastfeeding difficulties, may safely breastfeed in skin-to-skin contact with their mothers.

Relaxation and music reduce pain following intestinal surgery.

Three nonpharmacological nursing interventions, relaxation, chosen music, and their combination, were tested for pain relief following intestinal (INT) surgery in a randomized clinical trial. The 167 patients were randomly assigned to one of three intervention groups or control and were tested during ambulation and rest on postoperative days 1 and 2. Pain sensation and distress were measured with visual analog scales (VAS). Multivariate analysis of covariance showed significantly less post-test pain in the intervention groups than in the control group on both days after rest and at three of six ambulation post-tests (p = .024-.001), resulting in 16-40% less pain. Mixed effects after ambulation were due to the large variation in pain and difficulty relaxing while returning to bed; but post hoc explorations showed effects for those with high and low pain. These interventions are recommended along with analgesics for greater postoperative relief without additional side effects.

Grief, anxiety, stillbirth, and perinatal problems: healing with kangaroo care.

A young, anxious mother's first pregnancy was eclamptic, her placenta was underperfused, and her son was stillborn. She carried grief, guilt, anxiety, and hypervigilance into her next preeclamptic pregnancy, birth (of her small-for-dates son), and early postpartum period. When breastfeeding difficulties developed, the authors intervened with three consecutive (skin-to-skin) breastfeedings. During the first skin-to-skin breastfeeding, the mother stopped crying, shared self-disparaging emotions, and then began relaxing and "taking-in" her new baby. Breastfeeding continues at 1 year.

Obtaining parotid saliva specimens after major surgery.

The purpose of this study was to develop and test a standard method of collecting saliva from postoperative patients. Saliva was collected from patients following major abdominal surgery from both parotid glands in intraoral cups and measured in milliliters. Trained research nurses stimulated saliva production with lemon juice and collected saliva at 4 time points on postoperative day 2. Collection time was measured with a stopwatch, and flow rate was calculated by dividing the amount in milliliters by collection time in minutes. Attrition was 9% due to ineligibility after enrollment and 1 withdrawal. In participating patients (n = 68), there were 272 tests planned and 28% were missing. The reasons were postoperative health problems, hospital discharge, and not wanting to be bothered. When saliva collection attempts were made, three-fourths were successful, but the remainder resulted in "dry mouth." Milliliters, minutes, and flow rate were calculated with and without those with dry mouth. Mean flow rates were 0.23 to 0.33 ml/min excluding those with dry mouth and 0.17 to 0.24 ml/min including those with dry mouth. Saliva variables were correlated with antihypertension medications, opioids, opioid side effects, and length of surgery, but statistically significant correlations were not found consistently at all 4 time points. The findings suggest that nurse-researchers studying biological markers can successfully collect saliva from postoperative patients if they recognize the difficulties and make efforts to minimize and control for them.

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.

Development of an observational instrument to measure mother-infant separation post birth.

The importance of the timing, quality, and quantity of early maternal-infant contact has gained prominence over the years. However, no researcher has adequately documented the nature of maternal-infant contact and separation. This study assessed the psychometric properties of the Index of Mother-Infant Separation (IMIS), pronounced "I miss," which is a 37-item observational measure of the process of mother-infant contact or separation post birth. Assessment of reliability and validity of the IMIS was conducted using data collected in a randomized clinical trial with 224 healthy newborn infants assigned at 1 hour post birth to self-regulatory or routine nursery care (control) groups. Time-sampled observations occurred every 15 minutes. Content validity indices of the IMIS, determined by nine nationally known perinatal experts, were 77% to 100% for instrument items. Construct validity was supported through known-groups hypothesis testing (p < .0001). Interrater reliability was from 86% to 90%. The IMIS is a valid observational measure of maternal contact when raters are trained to score it reliably.

Mother-newborn contact in a randomized trial of kangaroo (skin-to-skin) care.

OBJECTIVE: To describe the type and percent time of contact 0-48 hours postbirth for mother-preterm newborn (infant) dyads given kangaroo care (skin-to-skin) or standard care (controls). DESIGN: Randomized controlled trial with assignment by computerized minimization to kangaroo care (n = 48) or control (n = 43). SETTING: Postpartum units and neonatal intensive-care units (NICU). PARTICIPANTS: Preterm infants 32 to less than 37 weeks gestation and their mothers. INTERVENTION: Kangaroo (skin-to-skin, SS) care (KC). MAIN OUTCOME MEASURES: Type and percent time of mother-infant contact (SS versus holding wrapped in blankets). RESULTS: Analyses were based on four groups: assignment for infants in each group to postpartum or NICU. For KC dyads, SS postpartum was 22.0%; SS NICU was 7.5%. KC wrapped holding postpartum was 11.6%; NICU was 1.8%. For control dyads, wrapped holding postpartum was 13.9%; NICU was 6.1%. CONCLUSION: Amount of SS was much less than expected. Reasons include unavailability of infants or mothers and hospital staff interrupting contact. However, KC postpartum dyads were held wrapped almost as often as control postpartum dyads. Total contact time for KC dyads (SS plus wrapped) was more than double that of controls. These data suggest that hospital and social supports for families are needed to facilitate early initiation of SS, prolonged periods of mother-infant SS contact, and reduction of maternal stress.

Kangaroo (skin-to-skin) care with a preterm infant before, during, and after mechanical ventilation.

Using kangaroo care (KC) with unstable and/or ventilated infants remains controversial. In this article, potential advantages for ventilated infants and their mothers are discussed. The 33-week-gestation infant in this case study presented with mild respiratory distress at birth, requiring supplemental oxygen at hour 2. With no improvement by hour 18, KC was also begun, first for 1.25 hours and then, 2 hours later, for 3.5 hours. The infant was intubated at hour 45 for increasing respiratory distress, and KC resumed 24 hours later for 1 hour and 3 hours after that for an additional 3 hours. Extubation occurred at hour 90. Kangaroo care resumed 2 hours later for periods of 1.5, 1.5, and 1 hour over the next 8 hours, 2.5 hours more later that day (day 5, the last day of data collection). Thereafter, KC was done intermittently until discharge on day 9. Total KC times for pre-vent, vent, and immediate post-vent periods were 4.75, 4, and 6.5 hours, respectively. The data from this study suggest that KC may assist in, rather than retard, recovery from respiratory distress. KC may also foster maternal relaxation and minimize maternal stress.

Effects of prone and supine positions on sleep state and stress responses in mechanically ventilated preterm infants during the first postnatal week.

BACKGROUND/RATIONALE: Preterm infants in mechanical ventilation are vulnerable and may manifest physiological instability and a disorganized behavioural state when responding to external stimuli. Adequate positioning strategies may play an important role in protecting infants from environmental stressor and assisting quality of sleep. However, no study has examined effects of prone and supine positions on behavioural state and stress signs including startle, tremor, and twitch responses for ventilated preterm infants during the critical first week postbirth. AIM OF THE STUDY: The purpose of this study was to compare effects of prone and supine positions on behavioural state and stress responses in mechanically ventilated preterm infants. DESIGN/METHODS: The infants were aged 25-36 weeks of gestation, < or = 7 days of age, and without sedation or congenital abnormalities. Using a crossover design, 28 infants were randomly assigned to supine/prone or prone/supine position sequence. Infants were placed in each position for 2 hours. A stabilization period of 10 minutes before observation of each position was allowed. During the protocol, care procedures were kept minimal and ventilator settings remained unchanged. Behavioural state and frequencies of stress signs including startle, tremor, and twitch were systemically recorded and analysed with repeated measures analysis of variance. FINDINGS: Infants when prone compared with supine had (a) less crying, less active sleep, and more quiet sleep states, and (b) fewer stress responses of startle, tremor, and twitch. CONCLUSION: Results indicate that prone positioning improves the quality of sleep and decreases stress for ventilated preterm infants during the first week postbirth. These may conserve energy and assist infants' extrauterine adaptation.

Kangaroo care for adoptive parents and their critically ill preterm infant.

In this case study kangaroo care (KC) was facilitated for an adoptive mother and father who were planning to attend the birth of the infant they had arranged to adopt. Unexpectedly, the birth mother delivered at 27 weeks gestation. The infant was critically ill and required mechanical ventilation. However, in this neonatal intensive care unit where all adoptive parents and parents of mechanically ventilated infants are offered KC, these adoptive parents began KC on Day 3 while their infant daughter was still mechanically ventilated. She thrived thereafter and the entire experience was profoundly beneficial for this beginning family both at the hospital and after discharge home.