Respiratory tract outbreak modeling with case definition criteria: A proposal for a standardized clinical approach in nursing homes.

OBJECTIVES: This study aimed to monitor respiratory tract outbreaks in nursing homes (NH) by applying standardized case definition criteria, pathogen identification and estimated mortality impact. PATIENTS AND METHODS: This longitudinal, observational study described NH outbreaks with temperature (T°), upper respiratory sign, lower respiratory sign (LRS), general status deterioration, general signs, and mortality. Viral examinations allowed for analysis of developing outbreaks based on positive, negative, or no tests (Flu+/Flu-/NT-Flu). RESULTS: Forty-six influenza identification episodes (Flu+, 1067 patients), 14 Flu- (409 patients), and 18 NT-Flu (381 patients) were analyzed. Viral examinations were conducted mainly among residents with T° (84.8% [302/356]). A specific temperature pattern was observed in Flu+ outbreaks: 35.1% of infected residents with T° without LRS, 15.6% in Flu- episodes, and 17.1% vs. 29.1% in LRS without T°. A median temperature (MT) of ≥38.3 °C was observed in Flu+ outbreaks. MT analysis of the 18 NT-Flu episodes identified five outbreaks with high temperatures (MT ≥38.2 °C) and high mortality. Conversely, the 13 NT-Flu outbreaks with lower MT (<38.0 °C) were associated with lower total mortality. Similar clinical pictures led to closely comparable all-cause mortality impacts, particularly in Flu+, Flu-, and NT-Flu with MT of ≥38.2 °C. CONCLUSIONS: Validated sign/symptom monitoring highlighted some specificities of respiratory NH outbreaks and could be a complementary approach, taking into account common and atypical clinical pictures, assessing mortality and initiating virological investigations and infection control measures.

[How do mothers experience skin contact with their very immature (gestational age 27-30 weeks), only days old premature infants?]. / Wie erleben Mütter Hautkontakt mit ihrem sehr unreifen (Gestationsalter 27-30 Wochen), erst wenige Tage alten Frühgeborenen?

BACKGROUND: Mothers are offered skin-to-skin contact with their preterm infants with the intention to promote bonding. But it is not known if the mother of a very immature fragile infant perceives skin-to-skin contact as a helpful intervention or a stressful situation. PATIENTS AND METHODS: Mothers of singleton preterm infants (gestational age 27-30 weeks) began skin-to-skin contact as soon as the infant was breathing spontaneously. They prospectively documented frequency and duration of skin-to-skin contact, they rated their anxiety or confidence and their attachment to the infant and described their observations of the infant daily for 14 days in a semi-structured questionnaire. RESULTS: 17 of 25 mother-infant-pairs in the observation period fulfilled the entry criteria, 14 questionnaires about 196 skin-to-skin periods could be analyzed (median gestational age 27.5 weeks (27-30), median birth weight 1130 g (695-1300). Skin-to-skin contact began at a median age of 3 days [2-7]. The median duration of the skin-to-skin periods was increased at maternal request from 60 to 120 minutes between day 1 and 14 (p = 0.004). Even then 21% of the mothers wanted a still longer duration of skin-to-skin contact. Mothers reported anxiety only 5 times. 82% of the mothers reported positive own feelings during skin-to-skin contact and 78% felt that skin-to-skin contact increased their attachment to their infant. CONCLUSION: The mothers studied perceived skin-to-skin contact with their very immature infants as a positive and helpful intervention. Skin-to-skin contact took place regularly and for increasing periods of time.

Effects of gestational and postnatal age on body temperature, oxygen consumption, and activity during early skin-to-skin contact between preterm infants of 25-30-week gestation and their mothers.

Temporary skin-to-skin contact between preterm infant and the mother is increasingly used in neonatal medicine to promote bonding. It is not known at which gestational age (GA) and postnatal age skin-to-skin contact outside the incubator is a sufficiently warm environment and is tolerated by preterm infants without a decrease in body temperature, oxygen consumption (VO2) increase, or unrest. We conducted a prospective clinical study of 27 spontaneously breathing preterm infants of 25-30-wk GA. Rectal temperature (Trecta), VO2 (indirect calorimetry), and activity were continuously measured in the incubator (60 min), during skin-to-skin contact (60 min), and back in the incubator (60 min) in wk 1 and 2 of life. In wk 1 the change in Trectal during skin-to-skin contact was related to GA (r=0.585, p=0.0027): infants of 25-27-wk GA lost heat during skin-to-skin contact, whereas infants of 28-30 wk gained heat and their mean Trectal during skin-to-skin contact was 0.3 degrees C higher than before (p < 0.01). No significant changes of VO2 or activity occurred. In wk 2 the infants' VO2 was higher than in wk 1, but VO2 during skin-to-skin contact was the same as in the incubator. Only small fluctuations in Trectal occurred. In wk 2 all infants slept more during skin-to-skin contact than in the incubator (p < 0.02). We conclude that, for preterm infants of 28-30-wk GA, skin-to-skin contact was a sufficiently warm environment as early as postnatal wk 1. For infants of 25-27-wk GA skin-to-skin contact should be postponed until wk 2 of life, when their body temperature remains stable and they are more quiet during skin-to-skin contact than in the incubator.

Body temperatures and oxygen consumption during skin-to-skin (kangaroo) care in stable preterm infants weighing less than 1500 grams.

BACKGROUND: More and progressively smaller preterm infants are taken out of the incubator and placed skin to skin on their mother's chest to promote bonding, despite concerns that the infants are exposed to cold during this intervention. OBJECTIVE: To test the hypothesis that skin-to-skin care is a cold stress for preterm infants weighing less than 1500 gm, with a decrease in rectal temperature, a decrease in peripheral skin temperature, or an increase in oxygen consumption compared with conditions monitored during incubator care. STUDY DESIGN: We studied 22 stable, spontaneously breathing preterm infants weighing less than 1500 gm (appropriate in size for gestational age), who had their first skin-to-skin care in the first week of life. We continuously measured rectal temperature, peripheral skin temperature (foot), and oxygen consumption (indirect calorimetry) for 1 hour in a thermoneutral incubator, during 1 hour of skin-to-skin care, and for another hour in the incubator. Mean values for the three periods were compared by analysis of variance. RESULTS: During skin-to-skin care the mean rectal temperature was 0.2 degree C (p < 0.01) and the peripheral skin temperature was 0.6 degree C (p < 0.01) higher than during the preceding hour in the incubator. Back in the incubator, body temperatures returned to values recorded before skin-to-skin care. Oxygen consumption during skin-to-skin care (6.1 +/- 0.9 ml/kg per minute) was not significantly higher than in the incubator (5.8 +/- 0.8 ml/kg per minute). CONCLUSION: For stable preterm infants weighing less than 1500 gm and less than 1 week of age, 1 hour of skin-to-skin care is not a cold stress compared with care in a thermoneutral incubator.

Comparison of face mask, head hood, and canopy for breath sampling in flow-through indirect calorimetry to measure oxygen consumption and carbon dioxide production of preterm infants < 1500 grams.

Complete sampling of expired air is essential for accurate O2 consumption(CO2 production) [VO2(VCO2)] measurements with flow-through indirect calorimetry. In preterm infants complete sampling is critical, because only low sampling flows can be used. The accuracy of the various breath sampling systems at low flows and their patient compatibility is untested. We therefore measured 1) the accuracy of VO2(VCO2) measurements with a face mask, a head hood, and a canopy in vitro at low sampling flows; 2) the effect of breathing on measurements with the face mask; and 3) the effect of breath sampling systems on activity and body temperature of preterm infants. VO2(VCO2) were measured with a Deltatrac II. In vitro we used a methanol miniburner incorporated into a doll, which could simulate low VO2(VCO2) and tidal breathing. In vivo we studied seven preterm infants < 1500 g. With the face mask VO2(VCO2) measurements were accurate at a flow of 3 L/min (error -1 +/- 0.8%), when tidal volume was < 15 mL/breath and the distance between mask and manikin < 1 cm. With hood and canopy VO2(VCO2) were underestimated at a flow of 3 L/min (error -13 +/- 1% and -14 +/- 5%), and results were markedly influenced by body position. For accurate measurements, the hood needed a flow of 4.5 L/min, the canopy 8.3 L/min. In vivo the face mask did not increase heart rate, respiration, activity, or rectal temperature, but hood and canopy increased rectal temperature by 0.3-0.4 degree C. For VO2(VCO2) measurements in infants < 1500 g, a face mask should be used, which is accurate at low flows and does not change body temperature. Accuracy at low flows and patient compatibility of breath sampling systems should be evaluated and reported for VO2(VCO2) measurements in preterm infants.