Perhaps a kinder, gentler start to life is important. Several thoughts that bring this up are consideration of studies regarding delayed cord clamping, skin to skin care, and provision of breast milk. Even consider the relatively new neonatal resuscitation guidelines that remind us a slow transition at birth is better. Intervention with oxygen too early or too much may lead to complications down the road rather than improvement. Pink color is no longer expected in the first 30 seconds of life. Just breathe!! And, as the baby begins to breathe without intervention, a few seconds of time (30 to 120) in which the cord is still connected has benefit too. There are many studies now that show benefits of delayed cord clamping in preterm infants including fewer transfusions, less blood pressure problems in the first hours of life leading to less need for additional fluids or vasopressors, less intraventricular hemorrhage, less late onset sepsis and improvement in respiratory outcomes.1-4
Skin-to-skin or Kangaroo Care is beneficial in the first few minutes of life and has been linked with better establishment of breast feeding. Ongoing or intermittent skin-to-skin care has been linked with improved breast feeding duration, exclusivity and milk production, as well as improved neurodevelopmental outcome, improvement in vital sign stability and other physiologic signs of stability.5 These benefits are observed after as little as 10 minutes or as much as 24/7 time in the skin-to skin-position with either mother or father. Sometimes these simple interventions don’t seem as important in a NICU where high tech is the norm. Skin-to-skin holding is delayed until the baby is stable enough, defined differently by different people. And giving the baby an opportunity to have some skin-to-skin time in the delivery room depends on many factors, such as the infant’s stability and the team’s comfort level with the extra time in delaying any intervention or resuscitation.
We see examples of the effect of maternal touch and presence in various animal studies. One study comparing orphaned versus mothered chimpanzees showed more socially appropriate play in the mothered chimpanzees, more aggression in the orphaned chimpanzees.6 This is important in human infants as well. One particular study evaluated infant responses to their own mother’s facial and vocal expression.7 These researchers found that infants as young as 3.5 months responded more to their own mother’s vocal expressions than stranger women.
Reports of the number of painful procedures experienced by the smallest and sickest infants are often over 200 per day. This trauma in early life can have an effect throughout life unless intentionally balanced with caring touch and communication. Perhaps over-balanced would be the better description. There is more and more work about trauma-informed care in neonatal patients. This work started in psychiatric patients since many are seen after trauma-filled lives. In the NICU infant, this trauma occurs in a disproportionate amount early in life. These early experiences, whatever they may be, shape the later lives of these infants. Families are the most appropriate to provide this comfort as we see that even very early, infant’s recognize the face and voice of their own mother and respond differently to this. Looking back at Erickson’s stages of development, we know that infancy is when trust is developed. This includes trust in the environment and in caretakers. Painful procedures should be minimized and managed with either pain medication or comfort so that trust can be established. A crying infant is obviously in distress – calming them is important to the establishment of trust.
So if skin-to-skin care is so important and simple, why isn’t it done more, particularly in the highest risk infants? In one systematic review, barriers to skin-to-skin care included time, social support, medical and family acceptance.8 Not surprisingly, positive perceptions of skin-to-skin care or a belief that it helped, on both the part of the healthcare worker and family increased the time spent in this type of care. Time on the part of the family is important as in most cases, parents are encouraged to spend at least one hour holding the infant and longer time periods are encouraged. With the infant hooked up to machines, this limits her movement. Comfortable chairs are a must! Time for the practice of skin-to-skin also applies to the healthcare worker. If there is not sufficient time to explain this type of care to parents and assist with the process, it is less likely to be done. In one study, the expansion of visiting hours led to an increase in the adoption of skin-to-skin holding.9
Social support refers to assistance from others to perform skin-to-skin care. Perhaps families are not able to visit much because of other children. Someone willing and able to care for their other children would allow them the time to come and hold the new infant in skin-to-skin for prolonged periods of time. Medical concerns were also a barrier. Concern on both the part of healthcare workers and family, often influenced by healthcare workers about very preterm infants, presence of endotracheal tubes and intravenous lines were reported. Knowledge of the advantages of skin-to-skin care, even in the presence of these devices, encouraged the practice. Uniform knowledge and protocols were an enhancement to the practice. Cooper and group reported on a project where staff in a NICU were uniformly educated about skin-to-skin care, how to assist parents and the advantages.10 They found an increase in the use of the practice after this education.
Providing breast milk is another basic measure of intervening naturally. And, it turns out, this is the most beneficial “medicine” we can give! Multiple studies now show a reduction in the incidence of necrotizing enterocolitis, less late onset sepsis, improved neurodevelopmental outcome, lower incidence of autoimmune disorders later in life and many other benefits to something so basic and low tech as the provision of breast milk. While providing the breast milk may not always be as low tech as we would like (pumps, tubes etc), it certainly can be once infants are able to suck and go directly to breast. At this point, the infant can also receive skin-to-skin which, it turns out, helps both mom and baby.
While technology and medicine save lives, we can’t forget the more basic practices that can enhance outcomes and perhaps prevent the need for at least some medicine.
Have you enjoyed Sandy’s blog post? Read another post in which she investigates
how nursing impacts family participation and healthcare dynamics in the NICU:
Read The NICU Nurse and Family Impact
- Mercer, J. S., McGrath, M. M., Hensman, A., Silver, H., & Oh, W. (2003). Immediate and delayed cord clamping in infants born between 24 and 32 weeks: a pilot randomized controlled trial. Journal of perinatology, 23(6), 466-472.
- Mercer, J. S., Vohr, B. R., McGrath, M. M., Padbury, J. F., Wallach, M., & Oh, W. (2006). Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemorrhage and late-onset sepsis: a randomized, controlled trial. Pediatrics, 117(4), 1235-1242.
- Rabe, H., Reynolds, G., & Diaz-Rossello, J. (2004). Early versus delayed umbilical cord clamping in preterm infants. Cochrane Database Syst Rev, 4. (reviewed 2010)
- Rabe H, Jewison A, Alvarex RF, Crook D, Stilton D, Bradley R, Holden D; Brighton Perinatal Study Group. (2011). Milking compared with delayed cord clamping to increase placental transfusion in preterm neonates: a randomized controlled trial. Obstet Gynecol. 117(2 Pt 1):205-11
- Ludington-Hoe, S. M., Morgan, K., & Abouelfettoh, A. (2008). A clinical guideline for implementation of kangaroo care with premature infants of 30 or more weeks’ postmenstrual age. Advances in Neonatal Care, 8(3), S3-S23.
- Van Leeuwen, E. J., Mulenga, I. C., & Chidester, D. L. (2014). Early social deprivation negatively affects social skill acquisition in chimpanzees (Pan troglodytes). Animal cognition, 17(2), 407-414.
- Kahana‐Kalman, R., & Walker‐Andrews, A. S. (2001). The role of person familiarity in young infants’ perception of emotional expressions. Child development, 72(2), 352-369.
- Chan, G. J., Labar, A. S., Wallb, S., & Atuna, R. Kangaroo mother care: a systematic review of barriers and enablers.
- De Vonderweid, U., Forleo, V., Petrina, D., Sanesi, C., Fertz, C., Leonessa, M. L., & Cuttini, M. (2003). Neonatal developmental care in Italian Neonatal Intensive Care Units. Italian Journal of Pediatrics, 29(3), 199-205.
- Cooper, L., Morrill, A., Russell, R. B., Gooding, J. S., Miller, L., & Berns, S. D. (2014). Close to me: enhancing kangaroo care practice for NICU staff and parents. Advances in Neonatal Care, 14(6), 410-423.