The Association of Kangaroo Mother Care, Energy Conservation, and Bonding in Preterm Neonates

Purpose:To examine the association of kangaroo mother care (KMC) on energy utilization and bonding as evidenced by reduced biochemical markers of adenosine triphosphate (ATP) degradation, hypoxanthine (Hx), xanthine (Xa), and uric acid (UA), and (allantoin), a measure of oxidative stress in preterm infants 24-36 weeks gestation. A secondary objective was to compare specific physiological parameters using bedside monitoring and perfusion and oxygenation of the gut using near-infrared spectroscopy (NIRS) during 1 hour of KMC compared to incubator care. Study design: A randomized controlled trial (RCT) examining the effects of 1-hour of KMC or 1-hour incubator care on urinary markers from samples collected 3-6 hrs before, and 3-6 hours after KMC. Preterm infants (n = 51) were assigned to intervention/control groups using stratified randomization based on weight. Urine concentrations of Hx, Xa, and UA were measured using high performance liquid chromatography (HPLC) and allantoin was quantified using gas chromatography-mass spectrometry (GC-MS) methods. Bonding was measured using the Mother-to-infant Bonding Scale, a reliable 8-item self-assessment scale linking early maternal moods to difficulties in bonding. Psychometric properties have demonstrated a two-factor model, good predictive validity, a sensitivity of 0.90 and specificity of 0.80 for a threshold score ≥ 2, and acceptable internal consistency (a= 0.71). Physiologic measures were captured using bedside monitoring and abdominal NIRS to capture gut perfusion and oxygenation. Results: There was a decrease in oxidative stress (p= 0.026) in the KMC group compared to incubator group.In both groups there were trending improvement in uric acid (p = 0.025) and xanthine (p= 0.042) over time, and in abdominal temperatures (p = 0.004) and perfusion index (p = 0.031) over time. No other physiologic or urinary measures showed statistically significant changes either between the groups or over time. A mixed model analysis of variance (ANOVA) was conducted with the use of unstructured covariance matrix adjusted using the Bonferroni method to assess the changes in the outcome measures of urinary purines and physiological measures. Mother-Infant Bonding scores were calculated using relative risk. The number and percentage of subjects who changed their MIBS scores from baseline to time 3 were measured, and the comparison of these changes between the KMC on DOL 3 and DOL 4 as measured by the Mother-Infant-Bonding-Scale (MIBS) in intervention and control groups were calculated. We found that scores showed that KMC mothers showed a higher risk of bonding problems than those in the control group. Nineteen percent more mothers in KMC group demonstrated an increase in MIBS score or a 26 percent increase relative risk for an increase of score (RR=1.26; 95% CI 0.97,1.63). However, the results were not statistically significant as the null value was included in the 95% confidence interval. Significance was set at an alpha of 0.05. Conclusions: This is the first study of its kind to evaluate the association of KMC on biochemical markers of stress and physiological parameters of abdominal near-infrared spectroscopy (NIRS) and abdominal temperatures in preterm infants 24-36 weeks gestation. The results of this study suggest that stress and inflammatory processes are decreased in the presence of KMC. Further research is needed to understand the role of biochemical markers and KMC and its implications in nursing research in preterm neonates and improved outcomes. This study has the potential to provide the physiological data to further support the benefits of energy conservation for recovery and growth in neonates

Placental function, body composition and cardiovascular autonomic function

Hypertension is an important modifiable risk factor for cardiovascular disease. An important recent advancement in hypertension research is an understanding that hypertension often may have a developmental origin. Birthweight is associated with hypertension across the lifespan and adult cardiovascular disease, such that those at both ends of the spectrum are at increased risk. Nonetheless, birthweight is a crude surrogate of fetal growth and it may be that quantification of body composition, may more accurately identify the “at risk” individual. A causative mechanism linking birthweight and cardiovascular risk is yet to be identified but may involve changes to the structure and function of organs including the placenta which may impair development and predispose individuals to later cardiovascular disease. The aims of this thesis were to investigate the associations between placental function, body composition and cardiovascular autonomic function. Studies outlines in this thesis indicate different mechanism control fat mass and fat free mass in the newborn and that placental weight partly mediates the association of maternal factors with newborn body composition. While low birthweight has previously been shown to be associated altered autonomic function in the infant our studies suggests that body fatness may provide information beyond that obtained from birthweight assessment alone. Previous studies have shown altered blood pressure control in those born preterm, our studies found altered cardiovascular outcomes even in the late preterm newborn. Assessment of body composition in children and adolescents at rest and in response to an exercise test suggests worsening of autonomic control due to adiposity and may develop over time during childhood and adolescence. Collectively, these results emphasise the implications of altered in-utero and early life exposures on cardiovascular outcomes

Parent infant sleep synchrony: A test of two infant sleep locations

This study contributes to the growing understanding of social sleep environments and their relationship to parent and infant behaviour and physiology by exploring the ways proximity and/or regularity of bed-sharing practice affect the physiology of parents and infants during triadic social sleep. The study explores the sleep physiology of 15 regularly and occasionally bed- sharing families, testing previous claims of shared sleep and arousals amongst breastfeeding mother infant dyads, and presents a new examination of the effects of proximity on mother infant physiology, and for the first time father infant physiology during bed-sharing compared to rooming in. Fifteen families considered low-risk for SIDS with breastfed infants less than 3 months of age were recruited from N. Tees region. Families either regularly slept their infant in a cot by the side of the parent's bed, or with the infant in the parent's bed. Circumstances under which co-sleeping was practised, and its frequency were assessed from sleep diaries, together with interview. Data were acquired by physiological monitoring via respiratory plethysmography bands, temperature probes (axillary and rectal), pulse oximeter probe (rubber type, not clip) and infra-red video capture over three nights (one adjustment night and two test nights) in the Durham University Sleep Lab. The two test night conditions were 1) infant sleeping in the parental bed 2) infant sleeping in a cot positioned next to the parental bed. Infant sleep/wake states were determined using cardio-respiratory video method. Sleep stages were subjectively assigned to 4 sleep state categories, awake (A WK), active asleep (REM), quiet sleep (QS) and indeterminate (IND), according to the characteristics predominant in any 1 minute epoch. Data from this study identified that mothers and infants experienced less time awake on bed-sharing nights and infants spent less time in Quiet sleep on the bed-sharing night; that regular bed-sharing infants experienced disruption to their sleep when separated from their mothers, but greater stability in their sleep physiology between by-the-bed sleeping and bed-sharing than occasional bed-sharing infants; that regularity of normal sleep condition only affected the shared sleep of regular bed-sharing mothers and infants on the bed-sharing night; and that sleep state synchrony and arousal synchrony were present amongst breastfeeding bed-sharing mothers and infants. Neither sleep condition nor regularity of normal bed-sharing practice made a discernable difference to paternal sleep state distribution and fathers did not demonstrate sleep state synchrony with their infants during social sleep. Paternal arousal behaviour was entirely unaffected by the location of the infant or their regular sleep location. Two noteworthy trends from the paternal data were that the absence of the father on the cot night affected both infant and mother sleep and that paternal habituation to sleeping practice was observed

Clinical studies of breathing during sleep and sudden infant death syndrome

The primary aim of the research reported in this thesis was to study breathing patterns during sleep in a) apparently normal symptom-free full-term infants, b) infants admitted to hospital during and following recovery from relatively minor illnesses, and c] infants thought to be at increased risk for Sudden Infant Death Syndrome CSIDS) - siblings of previous SIDS victims, and 'near-miss' for SIDS cases, to quantify apnoea (central and obstructive] and observe its effect on heart rate and transcutaneous oxygen tension, PtcO₂. Secondary aims were to study gross body movements (as an indicator of arousal], and to assess whether infants at 'increased risk' for SIDS were chronicallyhypoxaemic during the early months of life. Polysomniographic studies lasting three to five hours during the night recorded eye movements, digastric muscle tone, electrocardiogram^, electroencephalogram, airflow, chest and abdominal movements and PtcO₂ in 86 index cases and 11 healthy controls studied on 176 and 31 occasions respectively.The results were as follows:1. The 11 normal healthy infants did not have episodes of obstructive or prolonged (^-15 seconds] central apnoea during sleep.2. 33 'symptomatic' infants revealed: a] Bronchiolitis - apnoeic pauses were shorter than 15 seconds. Indices of central apnoea were increased significantly in quiet sleep during the index illness. Prolonged (≥ 6 seconds) obstructive apnoea was uncommon

Standardized Care of the Late Preterm Infant in Upper Midwest Hospitals

Standardizing care or critical pathways have delivered evidence-based care in adult medicine and have positive patient outcomes. Some aspects of standardized care have been used in neonatology, but less often in caring for the late preterm infant (gestational week 34-37 weeks). With each level of care nursery, Level-I, level-II or level-III, there can be a wide range of how to care for the late preterm infant. The purpose of this study was to determine if nurseries or various levels of care had established standards of care specific to the late preterm infant and what barriers existed that prohibited standards of care. A 10-questions survey was sent out to nurse leaders in Mid-western states and a follow-up interview of self-report responses was conducted on a random selection of the participants. Data revealed that standardized care for late preterm infants, including where the LPI gets admitted, use and discontinuation of thermoregulation, feedings, car seat testing and follow-up occurs more often in level-III nurseries and less often in level-I nurseries. Finding suggest that barriers to standardizing care for late preterm infants is often because of physician preferences, nursing staff attitude and experience level and facility constraints

Standardized Care of the Late Preterm Infant in Upper Midwest Hospitals

Standardizing care or critical pathways have delivered evidence-based care in adult medicine and have positive patient outcomes. Some aspects of standardized care have been used in neonatology, but less often in caring for the late preterm infant (gestational week 34-37 weeks). With each level of care nursery, Level-I, level-II or level-III, there can be a wide range of how to care for the late preterm infant. The purpose of this study was to determine if nurseries or various levels of care had established standards of care specific to the late preterm infant and what barriers existed that prohibited standards of care. A 10-questions survey was sent out to nurse leaders in Mid-western states and a follow-up interview of self-report responses was conducted on a random selection of the participants. Data revealed that standardized care for late preterm infants, including where the LPI gets admitted, use and discontinuation of thermoregulation, feedings, car seat testing and follow-up occurs more often in level-III nurseries and less often in level-I nurseries. Finding suggest that barriers to standardizing care for late preterm infants is often because of physician preferences, nursing staff attitude and experience level and facility constraints