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PubMed2000

Kangaroo mother care to reduce morbidity and mortality in low birthweight infants.

BACKGROUND: Kangaroo mother care (KMC), defined as skin-to-skin contact between a mother and her newborn, frequent and exclusive or nearly exclusive breastfeeding, and early discharge from hospital, has been proposed as an alternative to conventional neonatal care for low birthweight (LBW) infants. OBJECTIVES: To determine whether there is evidence to support the use of KMC in LBW infants as an alternative to conventional care after the initial period of stabilization with conventional care. SEARCH STRATEGY: We used the standard search strategy of the Neonatal Review Group of the Cochrane Collaboration. MEDLINE, EMBASE, LILACS, POPLINE and CINAHL databases, and the Cochrane Controlled Trials Register (Cochrane Library) up to Issue 2, 2000, were searched using the key words terms "kangaroo mother care" or "kangaroo mother method" or "skin-to-skin contact" and "infants" or "low birthweight infants". SELECTION CRITERIA: Randomised trials comparing KMC and conventional neonatal care in LBW infants. DATA COLLECTION AND ANALYSIS: Trial quality was assessed and data were extracted independently by two reviewers. Statistical analysis was conducted using the standard Cochrane Collaboration methods. MAIN RESULTS: Three studies, involving 1362 infants, were included. All the trials were conducted in developing countries. The studies were of moderate to poor methodological quality. The most common shortcomings were in the areas of blinding procedures for those who collected the outcomes measures, handling of drop outs, and completeness of follow-up. The great majority of results consist of results of a single trial. KMC was associated with the following reduced risks: nosocomial infection at 41 weeks' corrected gestational age (relative risk 0.49, 95% confidence interval 0.25 to 0.93), severe illness (relative risk 0.30, 95% confidence interval 0.14 to 0.67), lower respiratory tract disease at 6 months follow-up (relative risk 0.37, 95% confidence interval 0.15 to 0.89), not exclusively breastfeeding at discharge (relative risk 0.41, 95% confidence interval 0.25 to 0.68), and maternal dissatisfaction with method of care (relative risk 0.41, 95% confidence interval 0.22 to 0.75). KMC infants had gained more weight per day by discharge (weighted mean difference 3.6 g/day, 95% confidence interval 0.8 to 6.4). Scores on mother's sense of competence according to infant stay in hospital and admission to NICU were better in KMC than in control group (weighted mean differences 0.31 [95% confidence interval 0.13 to 0.50] and 0.28 [95% confidence interval 0.11 to 0.46], respectively). Scores on mother's perception of social support according to infant stay in NICU were worse in KMC group than in control group (weighted mean difference -0.18 (95% confidence interval -0.35 to -0.01). There was no evidence of a difference in infant mortality. However, serious concerns about the methodological quality of the included trials weaken credibility in these findings. REVIEWER'S CONCLUSIONS: Although KMC appears to reduce severe infant morbidity without any serious deleterious effect reported, there is still insufficient evidence to recommend its routine use in LBW infants. Well designed randomized controlled trials of this intervention are needed.

Breast Feeding↗
PubMed2006

Analysis of mother-infant interaction in infants with down syndrome and typically developing infants.

Delays in development of early social behaviors in babies with Down syndrome are likely to affect patterns of interaction with their caregivers. We videotaped 23 babies in face-to-face interaction with their mothers at 8 and 20 weeks of age and compared them to 23 typically developing infants and their mothers. Social behaviors, mothers' behaviors, and quality of interaction were rated. At 8 weeks, babies with Down syndrome were significantly less communicative and lively than the typically developing babies. Their mothers' behaviors did not differ at 8 weeks, but did at 20 weeks. Although the social behaviors of babies with Down syndrome improved over time, qualitative differences remained.

Adult↗
PubMed1996

Maternal and non-maternal time-allocation to infant care, and care during infant illness in rural Java, Indonesia.

An estimated 60% of women in Central Java are engaged in income-generating work. This study addresses the manner in which mothers allocate time to infant care as well as to household maintenance and employment. The study investigates the time-allocation to infant care by non-maternal carers, both among infants whose mother is involved in income-generating work and among infants whose mother is not employed. The longitudinal study followed 60 households, one infant per household, of the age range 3-25 months (mean infant age over the course of the study was 13.8 months). Each household was visited every 7 to 10 days from February 1991 through June 1991. One observation day and two separate recall-days were recorded per month. Daily time allocation (6 a.m. to 6 p.m.) to infant care by the mother and other individuals, frequency and minutes of breastfeeding, and infants' non-breastmilk kilocalorie intake were recorded. In addition, mothers recorded any infant symptom(s) on a daily calendar provided to them, and this symptom-data and information on any treatments and/or help-seeking for the infant was collected every 7-10 days. One or more non-maternal caretaker participated in infant care on 90% of the total sample days, for a median of 3 hr 15 min (mean 3 hr 50 min per day), and participated in infant feeding on one-third of all sample days. Grandmothers, sisters, and fathers of the infants were the most important in terms of time allocated to infant care. One or more sister cared for the infant on 30% of total sample days (mean 180 min, median 150 min, 5-645 min), the father on 55% of sample days (mean 90 min, median 65 min, 5-600 min), and grandmother(s) on 32% of sample days (mean 160 min, median 130 min, 5-670 min). Non-maternal care was also substantial during days of symptom-reporting; other carers participated in infant-care on 84% of days, and fed the infant on 28% of days. The study findings suggest that health education messages related to infant care and feeding could be usefully targeted to other persons in addition to mothers. Infant care on symptom-free days were compared to symptom-days using Wilcoxon matched-pair test within each data-collection month (round). While no significant differences were found for the time-allocation to infant care by the mother or others on symptom-days compared to symptom-free days, there was a mean 25% lower non-breastmilk kilocalorie intake on symptom-days (P = 0.00) in four of five data-collection rounds. Mothers reported that lack of appetite accompanied other symptom(s) on 46% of the days of help-seeking in the modern sector. This reflects the mothers' concern for infant appetite in association with illness.

Adult↗
PubMed1995

Total body bone mineral content in small-for-gestational -age, appropriate-for-gestational -age, large-for-gestational -age term infants and appropriate-for-gestational -age preterm infants.

BACKGROUND: Metabolic bone disease is a recognized complication in very low birth weight infants. Inadequate postnatal intake of calcium and phosphorus is probably important in the pathogenesis of bone disease in the newborn. A few studies have shown lower bone mineral content at birth in small for gestational age (SGA) than in appropriate for gestational age (AGA) infants. The present study was designed to compare total body bone mineral (TBBM) content in AGA, SGA, and large for gestational age (LGA) term infants. Also, it was designed to evaluate extrauterine changes in TBBM in preterm infants. METHODS: Ten SGA [mean +/- S.D. birth weight (B.W.) was 1.7 +/- 0.2 Kg, gestational age (G.A.), 39.0 +/- 0.8 weeks], ten AGA (B.W.; 3.3 +/- 0.4 Kg; G.A.: 39.3 +/- 1.4 weeks), ten LGA (B.W.: 4.4 +/- 0.3 Kg; G.A.: 40.4 +/- 0.9 weeks) term infants and ten AGA preterm infants (B.W.: 1.6 +/- 0.3 Kg; G.A.: 31.9 +/- 1.9 weeks) were enrolled in this study. TBBM content was measured using dual-photon-absorptiometry at 1 week postnatally in SGA, AGA, LGA term infants and in preterm infants at 1, 6, 12 weeks postnatally. Serum total calcium, phosphorus, magnesium, alkaline phosphatase activity (alk-p), parathyroid hormone (PTH), 25-hydroxyvitamin D (25-OHD) and urinary calcium, phosphorus, creatinine were measured at 1 week postnatally in all studied infants and 6, 12 weeks, postnatally in preterm infants. Preterm and SGA term infants received premature formula enriched with calcium, phosphorus and vitamin D. RESULTS: There was no significant difference (p > 0.05) in serum calcium, phosphorus, magnesium, alk-p, PTH, 25-OHD and urinary calcium, phosphorus, creatinine values among SGA, AGA and LGA term infants at one week of age. Also, there was no significant difference in serum biochemical values in preterm infants at 1, 6, 12 weeks postnatally. Significantly lower (p < 0.05) urinary phosphorus values were found in preterm than in term infants. TBBM content was lower (p < 0.05) in SGA term infants than in AGA and LGA term infants. Premature infants had lower (p < 0.01) TBBM values than term AGA infants; however, TBBM values increase with postnatal age in preterm infants. CONCLUSIONS: Biochemical or marked radiological evidence of metabolic bone disease did not develop in any of the studied preterm infants. It appears that feeding permature infants with formula enriched with phosphorus, calcium and vitamin D may provide sufficient mineral for bone mineralization.

Birth Weight↗
PubMed2001

Continuous nasogastric milk feeding versus intermittent bolus milk feeding for premature infants less than 1500 grams.

BACKGROUND: Most premature infants less than 1500 grams birth weight must be fed initially by tube because of their inability to suck effectively, or to coordinate sucking, swallowing and breathing. Milk feedings can be given by tube either intermittently, typically over 10-20 minutes every two or three hours, or continuously, using an infusion pump. Although theoretical benefits and risks of each method have been proposed, effects on clinically important outcomes remain uncertain. OBJECTIVES: To examine the evidence from randomized trials regarding the effectiveness of continuous versus intermittent bolus nasogastric milk feeding in premature infants less than 1500 grams. The primary outcomes reviewed included feeding tolerance, days to reach full enteral feeding, somatic growth, days to discharge and incidence of necrotizing enterocolitis (NEC). SEARCH STRATEGY: Searches were performed of MEDLINE, CINAHL, HealthSTAR, and the Cochrane Controlled Trials Register. As well, studies identified from abstracts and conference proceedings and references from relevant publications were retrieved. SELECTION CRITERIA: Randomized and quasi-randomized clinical trials that met the following criteria for relevance: a) Enrollment of infants < 1500 grams birth weight with no major congenital anomalies which might interfere with feeding tolerance b) Comparison of continuous nasogastric versus intermittent bolus tube feedings using breastmilk or formula c) Assessment of relevant outcomes including feeding tolerance, days to full feeds, somatic growth, days to discharge, and complications such as NEC or apnea DATA COLLECTION AND ANALYSIS: All articles retrieved from the complete search were assessed independently by the two reviewers for relevance (see selection criteria), and for methodologic quality using the following criteria: blinding of randomization, blinding of intervention, complete follow-up and blinding of outcome measurement. Only those articles judged by both reviewers to be relevant and to have appropriate methodologic quality were included in the analysis. Differences were resolved through discussion and consensus of the reviewers. MAIN RESULTS: Infants fed by continuous tube feeding method took longer to reach full enteral feeds (weighted mean difference 3.0 days; 95% CI 0.7, 5.2). Although there was no evidence of a difference in the days to discharge overall, one study suggested a trend toward earlier discharge for infants less than 1000 grams birth weight fed by the continuous tube feeding method (mean difference (MD) -11days; 95% CI -21.8, -0.2). Overall, there was no evidence of a difference in somatic growth (weight, length, head circumference or skinfold thickness) between the two groups, but subgroup analyses in one study suggested that infants less than 1000 grams and 1000 - 1250 grams birthweight gained weight faster when fed by the continuous tube feeding method (MD 2.0 g/day; 95% CI 0.5, 3.5; MD 2.0 g/day; 95% CI 0.2, 3.8, respectively). There was no evidence of a difference in the incidence of NEC. One study showed a trend toward more apneas during the study period in infants fed by the continuous tube feeding method (MD 14.0 apneas during study period; 95% CI -0.2, 28.2). REVIEWER'S CONCLUSIONS: Infants fed by the continuous tube feeding method took longer to reach full feeds, but there was no difference in somatic growth, days to discharge, or the incidence of NEC for infants fed by continuous versus intermittent bolus tube feeds. Small sample sizes, methodologic limitations and conflicting results of the studies to date, together with inconsistencies in controlling variables that may affect outcomes, make it difficult to make universal recommendations regarding the best tube feeding method for premature infants less than 1500 grams. The clinical benefits and risks of continuous versus intermittent nasogastric tube milk feeding cannot be reliably discerned from the limited information available from randomized trials to date.

Enteral Nutrition↗
PubMed2000

Prophylactic methylxanthine for extubation in preterm infants.

BACKGROUND: When preterm infants have been given intermittent positive pressure ventilation (IPPV) for respiratory failure, weaning from support and tracheal extubation may be difficult. A significant contributing factor is thought to be the relatively poor respiratory drive and tendency to develop hypercarbia and apnea, particularly in very preterm infants. Methylxanthine treatment started before extubation might stimulate breathing and increase the chances of successful weaning from IPPV. OBJECTIVES: Main question: in preterm infants being weaned from IPPV and in whom endotracheal extubation is planned, does treatment with methylxanthine reduce the use of intubation and IPPV, without clinically important side effects. SEARCH STRATEGY: The standard search strategy of the Neonatal Review Group, as outlined in the Cochrane Library, was used. SELECTION CRITERIA: All published trials utilising random or quasi-random patient allocation, in which treatment with methylxanthine (theophylline or caffeine) was compared with placebo or no treatment to improve the chances of successful extubation of preterm or low birth weight infants, were included. DATA COLLECTION AND ANALYSIS: The standard methods of the Cochrane Collaboration and its Neonatal Review Group were used. The second author assessed the quality of trials blinded to the authors and extracted data independently. Relative risk and risk difference was used in the meta-analysis. MAIN RESULTS: Overall analysis of the 4 published trials suggests that methylxanthine treatment results in a reduction in the use of mechanical ventilation. Three of the 4 studies are consistent with this overall result while one small trial (Barrington 1993) found no benefit. One study (Durand 1987) found that treatment was effective in those born at less than 1000 grams and who were less than one week old. In the small prespecified subgroups in this trial, infants of less than 1 kg birth weight and older than one week and those of birth weight 1000-1250 grams who had failed extubation once, no significant benefit could be shown. REVIEWER'S CONCLUSIONS: Implications for practice. Methylxanthines might increase the chances of successful extubation of some preterm infants but the results of this meta-analysis do not allow firm recommendations to be made for clinical practice. One trial suggests that this benefit is principally in infants of extremely low birth weight extubated in the first week. There are no trial data to support the routine use of methylxanthines for the extubation of infants with a birth weight over 1000 gms or those that are older than one week. Implications for research. Further trials are required comparing methylxanthines with placebo for extubation of very preterm infants. There is a need to stratify infants by gestational age (a better indicator of immaturity) rather than birth weight in future studies. Caffeine, with its wider therapeutic margin (Blanchard 1992) would be the better treatment to evaluate against placebo. Side effects and neuro-developmental status at follow up should be included in as outcomes.

Caffeine↗
PubMed1999

Assessment of infant cardiopulmonary resuscitation rescue breathing technique: relationship of infant and caregiver facial measurements.

OBJECTIVE: Although a few infants ever require resuscitation, pediatric cardiopulmonary resuscitation (CPR) is performed most commonly under 1 year of age. American Heart Association guidelines for pediatric basic life support recommend that the caregiver place his/her mouth over the infant's mouth and nose to create a seal. The way CPR is currently taught encourages parents to attempt to seal the nose and open the mouth of the infant for rescue breathing. Recent studies suggest some parents may have trouble sealing an infant's nose and open mouth, but their study participant numbers were small. The aim of this report is to estimate, among a large cohort, the ability of caregivers to create a seal to their infants for the provision of rescue breathing according to current guidelines. METHODS: Infants up to 1 year of age (n = 281) and their caregivers were enrolled from Philadelphia pediatric offices. Facial measurements of the infants were obtained to estimate the length needed to seal the nose and open mouth, and the nose and closed mouth. Mouth widths of the caregivers were compared with their infant's nose and mouth lengths. One-way analysis of variance with Tukey's postmortem analysis and ordinary least squares means regression were used for univariate analysis with analysis of covariance used to control for the effects of multiple variables when necessary. Infant measurements were stratified into 3-month age quadrants to compare against matched adult caregiver measurements. RESULTS: Most caregivers (n = 270) were female. Females had smaller mouth widths than males (4.9 +/- 0.5 cm vs 5.2 +/- 0.5 cm). Infant nose and mouth length increased during the first year of life, with the largest increase between 0 to 3 months and 3 to 6 months (4.2 +/- 0.4 cm to 4.7 +/- 0.4 cm). As infant age and face length increased, a progressively higher rate of adult females were estimated not to be able to cover their infant's nose and open mouth, with the greatest increase again between 0 to 3 months (9%) and 3 to 6 months (40%). All female caregivers except 1 were predicted to be able to seal their infant's nose and closed mouth by our measurements. CONCLUSIONS: Infant face length grows rapidly during the first year of life with the most rapid growth occurring during the first 6 months. As early as 3 to 6 months of infant age, many adult caregivers' facial measurements, especially female, predict that they may not be able to form a seal for mouth-to-nose and open-mouth infant rescue breathing. By related measurements, nearly 100% of caregivers should be able to seal their infant's nose and closed mouth. If facial measurement predictions correlate with functional inability to seal an infant's nose and open mouth, infant CPR rescue breathing instruction will need to emphasize head position and creation of a seal over the mouth and nose without teaching that the mouth be open. pediatric basic life support, infant CPR, rescue breathing, sudden infant death syndrome, acute life-threatening episode.

Adult↗