Immediate skin-to-skin contact for very preterm and low birth weight infants : from newborn physiology to mortality reduction

There is a contrast between the incidence of low birth weight and the contents and outcomes of neonatal care in high- versus middle- and low-income countries. Most of the neonatal deaths worldwide are attributed to low birth weight, occur within the first three postnatal days and can be prevented without intensive care. There are many benefits of skin-to-skin contact when initiated as per today’s recommendations, after an infant has become stable. Intermittent skin-to-skin contact is a component of neonatal care in Sweden. There is a knowledge gap concerning the effects of skin-to-skin contact initiated immediately after birth in unstable newborn very preterm and low birth weight infants. The overall aim of this thesis was to fill the knowledge gap on the effects of skin-to-skin contact initiated immediately after birth in unstable very preterm and low birth weight infants in high- as well as in low- and middle-income countries. More specifically, the aims were to investigate the cardiorespiratory effects and the effect on mortality. The five studies in this thesis derive from three randomised clinical trials comparing care in skin-to-skin contact immediately after birth with conventional care for very preterm or low birth weight infants, and from one register study. Studies I and II involved very preterm infants in Scandinavia, where study I (n=55) investigated the effect on infant temperature at one postnatal hour and study II (n=91) infant cardiorespiratory parameters during the first six postnatal hours. Study III (n=1475) reported on skin-to-skin contact initiation time and daily duration as per the Swedish Neonatal Quality Register. Study IV (n=3211) was a trial on the effect on neonatal mortality in low birth weight infants in Ghana, India, Malawi, Nigeria and Tanzania. Study V described the cardiorespiratory parameters during the first four days in the infants enrolled in study IV. Study I found that infants in skin-to-skin contact had 0.3°C lower temperature at one postnatal hour and study II that they had 0.52 points higher stability on a six-graded scale during the first six postnatal hours. Study III found that currently in Sweden, we initiate skin- to-skin contact for very preterm infants after half a day and daily durations of skin-to-skin contact amount to five hours during the stay in the neonatal unit. Study IV found 25% reduced neonatal mortality in low birth weight infants exposed to immediate and continuous skin-to-skin contact. Study V found similar cardiorespiratory parameters during the first four days of life in the two allocations of the cohort of study IV. There were benefits of skin-to-skin contact initiated immediately after birth, in terms of cardiorespiratory stabilisation in very preterm infants in high-income countries and mortality reduction in low birth weight infants in low- and middle-income countries. Skin-to-skin contact immediately after birth was not part of the conventional care. Data were collected during different postnatal time periods in the studies and were thus not comparable in detail. Mother-neonatal intensive care units should be available where low birth weight infants are born and skin-to-skin contact integrated into the neonatal medical care. Future research should focus on risks and scale-up

Case report: Fatal outcome of pyridoxine-dependent epilepsy presenting as respiratory distress followed by a circulatory collapse

Pyridoxine-dependent epilepsy is a rare autosomal recessive disease usually associated with neonatal seizures that do not respond to common antiseizure medications but are controlled by pyridoxine administration. Because the symptoms can mimic common neonatal disorders, the diagnosis can be initially missed or delayed. We report a fatal case of a boy who was initially diagnosed with respiratory distress, birth asphyxia, and persistent pulmonary hypertension and whose condition rapidly deteriorated during the first day of life

Immediate skin-to-skin contact after birth ensures stable thermoregulation in very preterm infants in high-resource settings

Aim To investigate the impact of immediate skin-to-skin contact with a parent after birth on thermal regulation in very preterm infants. Methods This clinical trial was conducted in three neonatal intensive care units in Scandinavia from 2018 to 2021. Infants born between 28 + 0 and 32 + 6 weeks and days of gestation were randomised to immediate skin-to-skin contact or conventional care in an incubator during the first 6 postnatal hours. We report on a secondary outcome: serial measurements of axillary temperature. Results Ninety-one infants were randomised to skin-to-skin contact or conventional care. Mean (range) gestational ages were 31 + 2 (28 + 6, 32 + 5) and 31 + 0 (28 + 4, 32 + 6) weeks and days, mean birth weights were 1572 (702, 2352) and 1495 (555, 2440) grams, respectively. Mean (95%CI, p-value) temperatures were within the normal range in both groups, 0.2°C (−0.29, −0.14, p < 0.001) lower in the skin-to-skin contact group. The skin-to-skin contact group had a lower relative risk (95%CI, p-value) of developing events of hyperthermia, RR = 0.70 (0.50, 0.99, p = 0.04). Conclusions Very preterm infants, irrespective of clinical stability, do not develop hypothermia during immediate skin-to-skin contact after birth. Immediate skin-to-skin contact did protect against events of hyperthermia. Concerns about thermal regulation should not limit implementation of immediate skin-to-skin contact in high-resource settings.publishedVersio

Parents' experiences of immediate skin-to-skin contact after the birth of their very preterm neonates

OBJECTIVE: To explore parents' experiences of immediate skin-to-skin contact after the birth of their very preterm neonates and their perceptions regarding care and support from staff. DESIGN: A descriptive qualitative study. SETTING: Birth and neonatal units within a university hospital in Sweden. PARTICIPANTS: Six parent couples who co-cared for their very preterm neonates with skin-to-skin contact throughout the first 6 hours after birth. METHODS: We analyzed individual interviews using reflexive thematic analysis as described by Braun and Clarke. RESULTS: The parents' experiences of immediate skin-to-skin contact with their very preterm neonates were represented by the following three themes: A Pathway to Connectedness, Just Being in a Vulnerable State, and Creating a Safe Haven in an Unknown Terrain. Skin-to-skin contact helped the parents attain their roles as essential caregivers and provided a calming physical sensation that promoted parents' feelings of connectedness with their newborns. When parents provide skin-to-skin contact at birth, staff members need to recognize and address their vulnerability. A good relationship with nursing staff, which was mediated through staff behaviors and availability, facilitated skin-to-skin contact. CONCLUSION: Skin-to-skin contact initiated at birth with very preterm neonates was a valuable and empowering experience for parents and enhanced early bonding between parents and their newborns. Staff members should recognize that skin-to-skin contact between parents and neonates is an interactive process that has challenges and requires adequate support. Future research is warranted to understand the needs of nursing staff who provide initial care in the postpartum period. Furthermore, we recommend the implementation of maternal-neonatal couplet care