Experiences of maternity care among women at increased risk of preterm birth receiving midwifery continuity of care compared to women receiving standard care: Results from the POPPIE pilot trial.

BACKGROUND: Midwifery continuity of care models for women at low and mixed risk of complications have been shown to improve women's experiences of care. However, there is limited research on care experiences among women at increased risk of preterm birth. We aimed to explore the experiences of care among women with risk factors for preterm birth participating in a pilot trial (POPPIE) of a midwifery continuity of care model which included a specialist obstetric clinic. METHODS: A total of 334 pregnant women identified at increased risk of preterm birth were randomly allocated to either midwifery continuity of care (POPPIE group) or standard maternity care. Women in both groups were followed up at six-to-eight weeks postpartum and were invited to complete a postnatal survey either online or by post. An equal status exploratory sequential mixed method design was chosen to collect and analyse the quantitative postnatal survey data and qualitative interviews data. The postnatal survey included measures of social support, trust, perceptions of safety, quality of care, control during childbirth, bonding and quality of life. Categorical data were analysed with chi-squared tests and continuous data were analysed with t-tests and/or Mann-Whitney U test to measure differences in measures scores among groups. The qualitative interview data were subjected to a thematic framework analysis. Data triangulation brought quantitative and qualitative data together at the interpretation stage. FINDINGS: A total of 166 women completed the survey and 30 women were interviewed (90 and 16 in POPPIE group; 76 and 14 in standard group). We found survey respondents in the POPPIE group, compared to respondents in the standard group, were significantly more likely to report greater trust in midwives (Mann-Whitney U, p<0.0001), greater perceptions of safety during the antenatal care (t-test, p = 0.0138), have a particular midwife to contact when they needed during their pregnancy (t-test, p<0.0001) and the postnatal period (chi-squared, p<0.0001). They reported increased involvement in decisions regarding antenatal, intrapartum and postnatal care (t-test, p = 0.002; p = 0.008; p = 0.006 respectively); and greater postnatal support and advice about: feeding the baby (chi-squared, p<0.0001), handling, settling and looking after the baby (chi-squared, p<0.0001), baby's health and progress (chi-squared, p = 0.039), their own health and recovery (chi-squared, p = 0.006) and who to contact about any emotional changes (chi-squared, p = 0.005). There were no significant differences between groups in the reporting of perceptions of safety during birth and the postnatal period, concerns raised during labour and birth taken seriously, being left alone during childbirth at a time of worries, control during labour, bonding, social support, and physical and mental health related quality of life after birth. Results from qualitative interviews provided insight and depth into many of these findings, with women in the POPPIE group reporting more positive experiences of bonding towards their babies and more positive physical health postnatally. CONCLUSIONS: Compared with standard maternity care, women at increased risk of PTB who received midwifery continuity of care were more likely to report increased perceptions of trust, safety and quality of care. TRIAL REGISTRATION: ISRCTN (Number: 37733900); UK CRN (ID: 31951).

[Prematurity and music therapy: harmonic encounters?] / Prématurité et musicothérapie : rencontres harmoniques ?

Premature birth can cause complications of varying nature and intensity in the child's development. The developmental care given to babies born prematurely is of major importance to their physical and psychological development. After clinical assessment, music therapy can be integrated into this care. It is a source of observed benefits.

Advances in Management for Preterm Fetuses at Risk of Delivery.

Preterm birth accounts for only 11% of live births but contributes to up to 75% of neonatal mortality and more than half of long-term morbidity. Targeted interventions to reduce the most common causes of perinatal morbidity and mortality include intrapartum group B Streptococcus prophylaxis, magnesium sulfate for fetal neuroprotection, antenatal corticosteroids for fetal lung maturity, latency antibiotics for preterm premature rupture of membranes, and tocolysis to allow corticosteroid administration and transfer to a tertiary care center. This article reviews the evidence for interventions to improve outcomes for fetuses at risk for preterm delivery at different gestational ages.

Probiotic Lactobacillus rhamnosus GR-1 is a unique prophylactic agent that suppresses infection-induced myometrial cell responses.

Preterm birth (PTB) is a multifactorial syndrome affecting millions of neonates worldwide. Intrauterine infection can induce PTB through the secretion of pro-inflammatory cytokines and untimely activation of uterine contractions. In pregnant mice, prophylactic administration of probiotic Lactobacillus rhamnosus GR-1 supernatant (GR1SN) prevented lipopolysaccharide (LPS)-induced PTB and reduced cytokine expression in the uterine muscle (myometrium). In this study we sought to delineate the mechanisms by which GR1SN suppressed cytokine secretion in the myometrium. We observed that L. rhamnosus GR-1 uniquely secretes heat-resistant but trypsin-sensitive factors, which significantly suppressed LPS-induced secretion of pro-inflammatory cytokines IL-6, IL-8, and MCP-1 in the human myometrial cell line, hTERT-HM. This effect was unique to GR1SN and could not be replicated using supernatant derived from non-GR-1 commensal lactobacilli species: L. rhamnosus GG, L. lactis, L. casei, or L. reuteri RC-14. Furthermore, pre-incubation of hTERT-HM cells with low-dose Pam3CSK (a TLR1/2 synthetic agonist which mimics LPS action) prior to LPS administration also significantly decreased LPS-induced cytokine secretion. This study highlights the distinct capacity of protein-like moieties secreted by L. rhamnosus GR-1 to inhibit pro-inflammatory cytokine production by human myometrial cells, potentially through a TLR1/2-mediated mechanism.

Role of massage therapy on reduction of neonatal hyperbilirubinemia in term and preterm neonates: a review of clinical trials.

BACKGROUND: Neonatal hyperbilirubinemia (NNH) is one of the leading causes of admissions in nursery throughout the world. It affects approximately 2.4-15% of neonates during the first 2 weeks of life. AIMS: To evaluate the role of massage therapy for reduction of NNH in both term and preterm neonates. METHOD: The literature search was done for various randomized control trials (RCTs) by searching the Cochrane Library, PubMed, and EMBASE. RESULTS: This review included total of 10 RCTs (two in preterm neonates and eight in term neonates) that fulfilled inclusion criteria. In most of the trials, Field massage was given. Six out of eight trials reported reduction in bilirubin levels in term neonates. However, only one trial (out of two) reported significant reduction in bilirubin levels in preterm neonates. Both trials in preterm neonates and most of the trials in term neonates (five trials) reported increased stool frequencies. CONCLUSION: Role of massage therapy in the management of NNH is supported by the current evidence. However, due to limitations of the trials, current evidences are not sufficient to use massage therapy for the management of NNH in routine practice.

Family Integrated Care (FICare) in Level II Neonatal Intensive Care Units: study protocol for a cluster randomized controlled trial.

BACKGROUND: Every year, about 15 million of the world's infants are born preterm (before 37 weeks gestation). In Alberta, the preterm birth rate was 8.7% in 2015, the second highest among Canadian provinces. Approximately 20% of preterm infants are born before 32 weeks gestation (early preterm), and require care in a Level III neonatal intensive care unit (NICU); 80% are born moderate (32 weeks and zero days [320/7] to 336/7 weeks) and late preterm (340/7 to 366/7 weeks), and require care in a Level II NICU. Preterm birth and experiences in the NICU disrupt early parent-infant relationships and induce parental psychosocial distress. Family Integrated Care (FICare) shows promise as a model of care in Level III NICUs. The purpose of this study is to evaluate length of stay, infant and maternal clinical outcomes, and costs following adaptation and implementation of FICare in Level II NICUs. METHODS: We will conduct a pragmatic, cluster randomized controlled trial (cRCT) in ten Alberta Level II NICUs allocated to one of two groups: FICare or standard care. The FICare Alberta model involves three theoretically-based, standardized components: information sharing, parenting education, and family support. Our sample size of 181 mother-infant dyads per group is based on the primary outcome of NICU length of stay, 80% participation, and 80% retention at follow-up. Secondary outcomes (e.g., infant clinical outcomes and maternal psychosocial distress) will be assessed shortly after admission to NICU, at discharge and 2 months corrected age. We will conduct economic analysis from two perspectives: the public healthcare payer and society. To understand the utility, acceptability, and impact of FICare, qualitative interviews will be conducted with a subset of mothers at the 2-month follow-up, and with hospital administrators and healthcare providers near the end of the study. DISCUSSION: Results of this pragmatic cRCT of FICare in Alberta Level II NICUs will inform policy decisions by providing evidence about the clinical effectiveness and costs of FICare. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02879799 . Registered on 27 May 2016. Protocol version: 9 June 2016; version 2.

A Stress Coping App for Hospitalized Pregnant Women at Risk for Preterm Birth.

BACKGROUND: Pregnant women hospitalized with preterm labor (PTL) complications experience increased stress. Prior researchers have attempted to provide stress management strategies with use of various media players to deliver stress coping interventions. PURPOSE: The purpose of this study was to examine the efficacy of a mobile device delivered stress coping app designed to reduce stress in a sample of high-risk pregnant women hospitalized with complications of PTL. METHODS: A descriptive study using a prospective mixed methods one-group pre/posttest design. Fifteen pregnant women used the mobile device app for 8 consecutive days. The app included study measures, educational overview of concepts, four guided imagery audio files to be listened to daily, and a stress self-assessment scale to be used before and after each use. Measures included: Perceived Stress Scale (PSS), Visual Analog Stress Scale (VASS), Coping Self-Efficacy Scale (CSES), and semistructured interviews. RESULTS: There was a significant drop in VASS scores when comparing scores before and after listening to the app (p < 0.0001). There were no significant differences between the baseline and Day 8 scores of PSS or CSES. All participants reported benefits from using the app and provided suggestions for improvement. CLINICAL IMPLICATIONS: The intervention reduced immediate stress and provided a respite from the stress response in this population. Maternal child nurses may consider incorporating stress coping interventions as standard care practice.

Lipid emulsions in the treatment and prevention of parenteral nutrition-associated liver disease in infants and children.

Long-term parenteral nutrition (PN) carries the risk of progressive liver disease in infants with intestinal failure. Although PN-associated liver disease (PNALD) is multifactorial in etiology, components of soybean oil lipid emulsions have been implicated in the disease's pathogenesis. Historically, infants with PNALD who were unable to wean from PN to full enteral feeding developed cirrhosis and end-stage liver disease, which require liver transplantation to survive. Over the past 2 decades, novel strategies for the management of parenteral lipids have improved morbidity and mortality from PNALD in infants with intestinal failure. Current strategies for the treatment of PNALD include restricting the dose of parenteral soybean oil lipid emulsion and/or replacing the soybean oil with a parenteral fish-oil lipid emulsion or emulsions of mixed-lipid sources. The purpose of this report is to review published data that evaluate these strategies in parenteral lipid management for the treatment and prevention of PNALD.

Inpatient care of small and sick newborns: a multi-country analysis of health system bottlenecks and potential solutions.

BACKGROUND: Preterm birth is the leading cause of child death worldwide. Small and sick newborns require timely, high-quality inpatient care to survive. This includes provision of warmth, feeding support, safe oxygen therapy and effective phototherapy with prevention and treatment of infections. Inpatient care for newborns requires dedicated ward space, staffed by health workers with specialist training and skills. Many of the estimated 2.8 million newborns that die every year do not have access to such specialised care. METHODS: The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops involved technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks" (or factors that hinder the scale up) of maternal-newborn intervention packages. For this paper, we used quantitative and qualitative methods to analyse the bottleneck data, and combined these with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for inpatient care of small and sick newborns. RESULTS: Inpatient care of small and sick newborns is an intervention package highlighted by all country workshop participants as having critical health system challenges. Health system building blocks with the highest graded (significant or major) bottlenecks were health workforce (10 out of 12 countries) and health financing (10 out of 12 countries), followed by community ownership and partnership (9 out of 12 countries). Priority actions based on solution themes for these bottlenecks are discussed. CONCLUSIONS: Whilst major bottlenecks to the scale-up of quality inpatient newborn care are present, effective solutions exist. For all countries included, there is a critical need for a neonatal nursing cadre. Small and sick newborns require increased, sustained funding with specific insurance schemes to cover inpatient care and avoid catastrophic out-of-pocket payments. Core competencies, by level of care, should be defined for monitoring of newborn inpatient care, as with emergency obstetric care. Rather than fatalism that small and sick newborns will die, community interventions need to create demand for accessible, high-quality, family-centred inpatient care, including kangaroo mother care, so that every newborn can survive and thrive.

Electrolyte and Mineral Homeostasis After Optimizing Early Macronutrient Intakes in VLBW Infants on Parenteral Nutrition.

OBJECTIVES: The aim of the present study was to evaluate electrolyte and mineral homeostasis in very-low-birth-weight (VLBW) infants who received high protein and energy intakes with a unique standardized parenteral nutrition solution containing electrolytes and minerals from birth onward. METHODS: Prospective cohort study in 102 infants with birth weight <1250 g. The evolution of plasma biochemical parameters was described during the first 2 weeks of life. RESULTS: During the first 3 days of life, mean parenteral intakes were 51 ±â€Š8 kcal · kg · day with 2.7 ±â€Š0.4 g · kg · day of protein, 1.1 ±â€Š0.2 mmol · kg · day of sodium and potassium, and 1.3 ±â€Š0.2 mmol · kg · day of calcium and phosphorus. Afterwards, most nutritional intakes (parenteral and enteral) met growth requirements. No infant developed a hyperkalemia >7 mmol/L, and a hypernatremia >150 mmol/L occurred only in 15.7% of the infants. In contrast, hyponatremia <130 mmol/L and hypokalemia <3 mmol/L occurred in 30.4% and 8.8% of the infants, respectively. The initial neonatal metabolic acidosis rapidly resolved in most infants and only 2.0% developed a base deficit >10 mmol/L after day 3 of life. Early hypocalcemia <1.8 mmol/L occurred in 13.7% of the infants. In contrast, hypophosphatemia <1.6 mmol/L occurred in 37.3% and hypercalcemia >2.8 mmol/L occurred in 12.7% of the infants. CONCLUSIONS: Increasing early protein and energy intakes in VLBW infants in the first week of life improves electrolyte homeostasis. It also increases the phosphorus requirements with a calcium-to-phosphorus ratio ≤1.0 (mmol/mmol) and the potassium and sodium requirements to avoid the development of a refeeding-like syndrome. These data suggest that the parenteral nutrition guidelines for VLBW infants for the first week of life need to be revised.

Zinc supplementation reduces morbidity and mortality in very-low-birth-weight preterm neonates: a hospital-based randomized, placebo-controlled trial in an industrialized country.

BACKGROUND: Zinc plays a pivotal role in the pathogenesis of many diseases and in body growth. Preterm neonates have high zinc requirements. OBJECTIVE: The objective of the study was to investigate the efficacy of zinc supplementation in reducing morbidity and mortality in preterm neonates and to promote growth. DESIGN: This was a prospective, double-blind, randomized controlled study of very-low-birth-weight preterm neonates randomly allocated on the seventh day of life to receive (zinc group) or not receive (control group) oral zinc supplementation. Total prescribed zinc intake ranged from 9.7 to 10.7 mg/d in the zinc group and from 1.3 to 1.4 mg/d in the placebo control group. The main endpoint was the rate of neonates with ≥ 1 of the following morbidities: late-onset sepsis, necrotizing enterocolitis, bronchopulmonary dysplasia, periventricular leucomalacia, and retinopathy of prematurity. Secondary outcomes were mortality and body growth. RESULTS: We enrolled 97 neonates in the zinc group and 96 in the control group. Morbidities were significantly lower in the zinc group (26.8% compared with 41.7%; P = 0.030). The occurrence of necrotizing enterocolitis was significantly higher in the control group (6.3% compared with 0%; P = 0.014). Mortality risk was higher in the placebo control group (RR: 2.37; 95% CI: 1.08, 5.18; P = 0.006). Daily weight gain was similar in the zinc (18.2 ± 5.6 g · kg⁻¹ · d⁻¹) and control (17.0 ± 8.7 g · kg⁻¹ · d⁻¹) groups (P = 0.478). CONCLUSION: Oral zinc supplementation given at high doses reduces morbidities and mortality in preterm neonates. This trial was registered in the Australian New Zealand Clinical Trial Register as ACTRN12612000823875.

Vitamin A supplementation in extremely low-birth-weight infants: subgroup analysis in small-for-gestational-age infants.

OBJECTIVE: Preterm infants with intrauterine growth restriction are at increased risk of respiratory distress syndrome and bronchopulmonary dysplasia (BPD). A randomized clinical trial by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Neonatal Research Network demonstrated that vitamin A supplementation in extremely low-birth-weight (ELBW) preterm infants requiring early respiratory support decreased the risk of developing BPD. STUDY DESIGN: A subgroup analysis of small-for-gestational-age (SGA) infants from the original NICHD trial was performed to test the hypothesis that in infants requiring early respiratory support, vitamin A supplementation decreases the relative risk of BPD or death in premature SGA infants to a greater extent than in gestational age-equivalent vitamin A-treated appropriate-for-gestational-age (AGA) infants. RESULTS: Although vitamin A supplementation significantly increased serum retinol concentrations in AGA ELBW infants (median [5th percentile, 95th percentile]: 16.3 [-7.0, 68.8] versus 2.4 [-13.9, 55.1]; p < 0.001), no increases were noted in SGA ELBW infants. CONCLUSIONS: Given the limited power of this analysis due to a low number of SGA infants, these data did not provide evidence to support the hypothesis that vitamin A supplementation in preterm SGA infants requiring early respiratory support decreases the relative risk of BPD or death as compared with preterm AGA infants.

Micronucleated erythrocytes in preterm newborns exposed to phototherapy and/or oxygentherapy.

Preterm newborns (PNBs) have an immature antioxidant defense system, and this makes them more susceptible to oxidative stress generated by postnatal treatments. The objective was to determine whether micronucleated erythrocytes increase in PNB by postnatal treatments such as oxygentherapy and phototherapy. We counted micronucleated erythrocytes and micronucleated polychromatic erythrocytes as DNA damage in 72 blood samples of PNB at 26-36 weeks of gestation, taken between 1 and 84 h after birth. We assume that more time passed between sampling and birth would correspond to greater time of exposure to oxygen (37 cases) and phototherapy plus oxygen (35 cases). In the PNB only exposed to oxygen, the differences were not significant, while there was a significant increase in micronucleated polychromatic erythrocytes with increasing exposure time in those treated with phototherapy plus oxygen. In conclusion, our results suggest that the MN increase from phototherapy can be observed in peripheral blood erythrocytes of PNB.

Effect of low versus high early parenteral nutrition on plasma amino acid profiles in very low birth-weight infants.

OBJECTIVE: To study the efficacy of early high doses parenteral nutrition (PN) versus early low dose with progressive increments PN regimens, we performed a prospective randomized study in very low birth-weight infants. STUDY DESIGN: Forty-one appropriate gestational age preterm infants with birth weights ranging from 750-1500 g were randomly assigned into two groups. In Group 1, infants started on 3.0 g/kg/day amino acids (AA) and 3 g/kg/day of 20% lipid; in Group 2, AA and lipid were started on 1 g/kg/day, and advanced over 3 days to a maximum 3 g/kg/day. Blood samples were obtained for AA concentrations before starting of the PN, and at the 7th and 14th days. RESULTS: The mean (±SD) birth weight was 1335 g (240), gestational age was 29.7 weeks (1.7) of the study group. The mean body weight and head circumference was similar in the Group 1 and Group 2 at the 14th postnatal days. There was no difference in the blood levels of triglyceride, blood urea nitrogen, creatinine, ammonia, lactat and bicarbonate in the two groups. There was no significant difference in the concentrations of AA except for arginine and asparagine. On day 14, the mean arginine concentrations were significantly higher and asparagine concentrations were lower in Group 2. CONCLUSION: Although earlier more aggressive administration of AA and fat is not associated with any significant metabolic abnormalities, growth rates and plasma AA concentrations of the infants were similar to infants who AA and lipid given lower in the first day of life.

The effect of kangaroo mother care on the duration of phototherapy of infants re-admitted for neonatal jaundice.

OBJECTIVE: We investigated the effect of kangaroo mother care (KMC) on the duration of phototherapy of jaundiced neonates. METHODS: Fifty Egyptian newborns hospitalized for jaundice were investigated through a prospective observational study to determine whether intermittent KMC would reduce the duration of phototherapy required. RESULTS: The babies who received KMC recovered earlier from jaundice and needed a shorter duration of phototherapy than the control group (68.14 ± 24.32 hour versus 100.86 ± 42.26 hour, p = 0.004). CONCLUSION: KMC may be an effective intervention to reduce the duration of phototherapy needed when jaundiced babies are hospitalized.

Music therapy as part of integrative neonatology: 20 years of experience - 3 case reports and a review.

BACKGROUND: Numerous varieties of interventions have decreased the mortality and morbidity of preterms. Due to the fact that more infants survive, developmental care has become a crucial topic. In this context, music therapy offers some interesting aspects for parents and children. Starting as an emotional approach, music therapy has developed towards a systematic therapeutic option in neonatal care. OBJECTIVES: To assess the relevance of music therapy for neonates. METHODS: We present 3 typical case reports and give an overview of the current literature regarding music therapy in neonatology. CASE REPORTS: Case 1: Focus on the child, especially the respiratory system. Case 2: Focus on care and assistance for the mother. Case 3: Focus on mother-father-child interaction. DISCUSSION: These cases show the varieties of indications and possible effects of music therapy. We discuss our own experience ranging over 20 years and give a review on the literature concerning the different aspects of music therapy in neonates. CONCLUSION: Probably without any severe adverse effects, music therapy has positive effects on basic vital signs, the reduction of pain and on neurological development. Furthermore, it grants the parents' wish to participate in the well-being of their child. Nevertheless, the need for a specific setting, its methods, and its positive as well as possible negative effects are still open issues and need scientific evaluation.

Determinants of oxidant stress in extremely low birth weight premature infants.

Early in life, premature neonates are at risk of oxidant stress. They often require total parenteral nutrition (TPN), which is, however, contaminated with oxidation products. Coadministration of parenteral multivitamins (MVP) with a lipid emulsion (LIP) prevents lipid peroxidation. We hypothesized that LIP+MVP induces a lower oxidant load compared to preparations in which MVP is administered with an amino acid solution (AA+MVP). The aim of this study was to compare markers of oxidant stress in premature neonates receiving LIP+MVP, either exposed to or protected from light, or AA+MVP. Antioxidant vitamins, the redox potential of glutathione, isoprostane, and dityrosine were measured in urine or blood sampled on days 7 and 10 from babies requiring low (<0.25) vs high (≥0.25) fractional inspired O(2). Oxygen supplementation induced a more oxidized redox potential and increased dityrosine with AA+MVP only. Adding MVP in the lipid rather than the amino acid moiety of TPN protects against the oxidant stress associated with O(2) supplementation. Photoprotection added no benefit. Blood transfusions were found to produce a pronounced oxidant load masking the beneficial effect of LIP+MVP. The impact of these findings relates to a strong association between a more oxidized redox potential and later bronchopulmonary dysplasia, a clinical marker of oxidant stress.

Preterm infant massage therapy research: a review.

In this paper, preterm infant massage therapy studies are reviewed. Massage therapy has led to weight gain in preterm infants when moderate pressure massage was provided. In studies on passive movement of the limbs, preterm infants also gained significantly more weight, and their bone density also increased. Research on ways of delivering the massage is also explored including using mothers versus therapists and the added effects of using oils. The use of mothers as therapists was effective in at least one study. The use of oils including coconut oil and safflower oil enhanced the average weight gain, and the transcutaneous absorption of oil also increased triglycerides. In addition, the use of synthetic oil increased vagal activity, which may indirectly contribute to weight gain. The weight gain was associated with shorter hospital stays and, thereby, significant hospital cost savings. Despite these benefits, preterm infant massage is only practiced in 38% of neonatal intensive care units. This may relate to the underlying mechanisms not being well understood. The increases noted in vagal activity, gastric motility, insulin and IGF-1 levels following moderate pressure massage are potential underlying mechanisms. However, those variables combined do not explain all of the variance in weight gain, highlighting the need for additional mechanism studies.