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Preterm Infants: Searching for the Perfect Treatment Plan

Does nurturing physical contact improve health and lower stress levels of infants born prematurely?

Catherine Meador

September 24, 2007

 

“The prematurely born infant emerges into a hectic, cold, noisy, and bright environment filled with mysterious equipment and peopled by masked strangers who try to help. Almost everything done to or for the infant is painful, and that pain can certainly be felt, although it cannot be communicated…The infant’s respirator roars away night and day keeping his or her lungs inflated and sustaining life—but at what price?” (Field 2003, 4)

 

(Clipart from clipartheaven.com)

 

 

 

 

 

 

A little bit of background…

 

Why are premature babies at risk?

 

          By definition, an infant is premature if he or she is born before the 37th week of pregnancy. Premature babies, often called “preemies”, are often very underweight and lacking self-sufficient organ function. (http://www.nlm.nih.gov/medlineplus/prematurebabies.html)

(http://www.babyzone.com/askanexpert/answer.asp?qid=14940)

 

How are premature babies cared for medically?

         

            Preemies are likely to need extensive medical care during the first hours and days of their life, and this care is generally administered in the neonatal intensive care unit, or the NICU. As medical technology has advanced, the survival rate of premature and low-birthweight infants has risen dramatically. This also means, however, that medical procedures performed on preterm infants are becoming more and more invasive. There are debates about how much and what kind of sensory stimulation is necessary and helpful for a preterm infant in the NICU. Thus, a major research field has developed studying the effects of medical procedures on preterm infants and the degree to which sensory stimulation is beneficial or harmful to an infant’s health.   

 

How could extra care and attention given to preterm infants possibly be a bad thing? Why study this issue at all?

 

          Early life of a preemie can be drastically different from that of a full-term infant. The NICU can be a stressful environment, and the medical procedures necessary to sustain life in low birth weight infants are disruptive to the natural process of the infant bonding with her parents and settling into her new surroundings. However, some people wonder if more attention and contact with the infants is always the best answer. Experts in the subject have conflicting opinions, some believing that additional tactile stimulation could adversely affect the infant who is already being fussed with and monitored around the clock. Studies have observed that less than 5% of contact with preterm infants in the NICU is primarily for the purpose of comforting the infant. Some researchers believe that this is out of worry that the preterm infants could be harmed by too much contact because they are so fragile (Harrison, 436). In order to ascertain the ideal treatment plan for premature infants needing medical care, researchers have focused specifically on a few questions:

·         Are preterm infants sensory-deprived in the NICU?

·         Are preterm infants over stimulated by too much physical contact, noise, or light in the NICU?

·         Is “prescribed” human touch—unrelated to treatment contact—beneficial to premature newborns in lowering their stress levels and increasing their overall wellbeing?

 

 

 

                                                (Clipart from clipartheaven.com)

 

Designing a clinical trial…

 

        How do researchers define and standardize treatment?

 

        Most everyone has an intuitive idea of what it means to hold and comfort a baby. However, in order to study the effects of loving and nurturing human contact on the health of a preterm infant scientifically, it is necessary to come up with some standard ways of talking about this physical contact and the sensory stimulation being “administered” to the newborns. Here are two of the most common terms used in the medical literature:

 

·         Gentle Human Touch (GHT): This is a common way of referring to the act of holding a newborn baby in a specific manner with the intention of providing comfort to them. By giving it a definition, researchers can use this term to refer to sensory contact with treatment subjects that is unrelated to standard medical care. In other words, GHT does not refer to any contact with the preterm infant that is due to administering any other kind of medical treatment. One study outlines their definition of GHT as follows: “The [research assistant] gently placed her left hand on the infant’s head with the fingertips resting immediately above the eyebrow line and the palm touching the infant’s crown. The right hand was placed with the right thumb on the infant’s right shoulder (at midline position) with the rest of her hand and fingers on the infant’s arm above the elbow.” (Talbott, 63)

·         Kangaroo Care (K Care): Similar to GHT, K Care specifically refers to bare skin contact between preterm infants and their parents. In one study addressing the effects of K Care on sleep time and restfulness in preterm infants, K Care is defined as “…the practice of holding a preterm infant, clothed only in a diaper, between the mother’s breasts or against a father’s bare chest skin-to-skin.” (Messmer, 408)

 

 

          How do we measure the effects of GHT and K Care on preterm infants?

         

          To answer the bigger question of a preterm infant’s need for touch and handling in the NICU, researchers typically monitor the presence of certain specific behavioral and physiological factors. Some observations commonly used to assess the stress level and the health of an infant are:

·         Quiet Sleep

·         Active Sleep

·         Inactivity (“percentage of time with no movement” Talbott, 63)

·         Motor Activity (“frequency of limb movements, body movements, head turnings, and startles” Talbott, 63)

·         Oxygen Saturation (measures lung capacity-- http://www.health.harvard.edu/diagnostic-tests/oxygen-saturation-test.htm)

·         Weight Gain

·         Behavioral Distress Cues (“facial grimacing, clenching of hands and feet, and mouthing behaviors” Talbott, 63)

·         Heart Rate

 

What the research shows…

 

àAccording to a 2003 study published in the Nursing Science Quarterly, infants whose treatment included 20 minutes of GHT displayed a positive difference in all of the physiological and behavioral factors compared to those who received basic medical care (the control group). The study was conducted over a ten-day period and the subjects were preterm boys and girls 27 to 32 weeks gestation. The following table summarizes data before and after the 10-day treatment period, as collected during 45 minutes of observation of the infants.

 

Comparison of Differences Between Control and Experimental Groups Between Measures on Day 17 and Day 6 During the 45-Minute Observations

 

Variable

Control Group

Experimental Group

T value

P (one-tailed)

No movement

1.4

4.4

-0.25

.40

Motor activity

3.06

-2.7

1.59

.065

Behavioral distress cues

1.07

-5.13

1.0

.16

Weight gain

184.5

232.5

-0.96

.18

Quiet sleep

-4.2

3.4

-0.65

.26

Active sleep

13.4

-9.6

1.7

.05 (statistically significant)

            On the whole, this data suggests that infants receiving GHT on a daily basis were more restful and slept more soundly than those who weren’t. It is worth noting, however, that the only behavioral difference recorded as being statistically significant was the decrease in active sleep. This could be reflective of a small sample size (in this case, N=20) and does not necessarily mean that the results aren’t at all valuable. The authors of the journal article hypothesize that the overall decrease in sleep is due to the increase in quiet sleep and thus interpret this as being in support of the hypothesis that GHT is beneficial to preterm infants. (Talbott, 65)

 

à In another ten-day study on the effectiveness of GHT in NICU treatment, researchers obtained similar results, observing a decrease in active sleep, motor activity, and behavioral distress in the experimental group. In this case, 84 infants were observed (42 in the experimental group and 42 in the control group). As was also the case in the previous study, no significant difference was found between the control and experimental group concerning oxygen saturation, heart rate, and weight gain (Harrison, 435).

 

àIn a 1997 study published in Pediatric Nursing, researchers specifically tested the effects of K Care on preterm infants. In this case (due to the nature of the treatment being tested—described above), subjects served as their own controls, and their parents were the ones administering treatment instead of nurses. Data was collected before, during, and after the infant was K Care treatment, and it was observed that infants generally slept better and were overall more restful during contact than before and after (Messmer, 408).

 

 

àAdditional Findings:

·         In a study published in 2006 in Pediatrics, it was found that skin-to-skin contact (SSC), which is similar in principal to GHT, improved sleep patterns in preterm infants.  These findings were based on monitoring of REM and non-REM sleep, and thus were more technical in their nature and focused more specifically on sleep (did not address as many other factors in infant behavior). (Ludington-Hoe, 909)

·         In a 1990 study published in Clinics in Perinatalogy, researchers observed improvements in restfulness and weight gain in infants that received “body stroking for five 1-minute segments covering the head and face region, neck and shoulders, back, legs, and supine infant’s limbs” (Field 1990, 6).

·         A 1998 study published in Journal of Tropical Pediatrics observed that touch stimulation raised the amount of oxygen absorbed into the bloodstream of preterm infants.  It should be noted, here, however, that this study only included data on seven preterm babies, and thus results should be interpreted accordingly (Daga, 170).

 

Conclusions…

 

        There are many different ways to study the effectiveness of certain nurturing practices in the NICU, and this summary presents merely a sampling of the information available. As a general rule, however, most research indicates that appropriate physical contact, when administered gently and regularly, serves to improve the overall condition of preterm infants receiving medical care in an intensive unit. More importantly, there is virtually no evidence, on the basis of this research, that such sensory stimulation is harmful to preterm infants. Therefore, the task for medical care providers is to develop practical treatment plans that maximize resources while providing neonates with enough attention and nurturing to enable them to prosper and maintain low levels of stress in a hectic hospital environment. 

 

 

References

 

1. Daga, S. R. et al. (1998). A Warm Touch Improves Oxygenation in Newborn Babies, Journal of Tropical Pediatrics, 44, 170-172.

 

2.  Field, Tiffany (1990). Alleviating Stress in Newborn Infants in the Intensive Care Unit. Clinics in Perinatology, 17, 1-9.

 

3. Field, Tiffany (2003). Stimulation of Preterm Infants. Pediatrics in review, 24, 4-11.

 

4. Harrison, Lynda Law et al. (2000). Physiologic and Behavioral Effects of Gentle Human Touch on Preterm Infants.  Research in Nursing & Health, 23, 435-446.

 

5. Ludington-Hoe, Susan M. et al. (2006). Neurophysiologic Assessment of Neonatal Sleep Organization: Preliminary Results of a Randomized, Controlled Trial of Skin Contact With Preterm Infants, Pediatrics, 117, 909-923.

 

6. Messmer, Patricia R. et al. (1997). Effect of Kangaroo Care on Sleep Time For Neonates, Pediatric Nursing, 23, 408.

 

7. Modcrin-Talbott, Mary Anne et al. (2003). The Biobehavioral Effects of Gentle Human Touch on Preterm Infants, Nursing Science Quarterly, 16, 60-67.

 

 

 

 

 

 

 

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