Cobedding and Recovery Time After Heel Lance in Preterm Twins: Results of a Randomized Trial

Women’s and Newborn Health Program, IWK Health Centre, Halifax, Nova Scotia, Canada.
PEDIATRICS (Impact Factor: 5.3). 08/2012; 130(3):500-6. DOI: 10.1542/peds.2012-0010
Source: PubMed

ABSTRACT Cobedding of preterm twin infants provides tactile, olfactory, and auditory stimulation and may affect pain reactivity. We carried out a randomized trial to assess the effect of cobedding on pain reactivity and recovery in preterm twin neonates.
Stable preterm twins (n = 67 sets) between 28 and 36 weeks of gestational age were randomly assigned to a cobedding group (cared for in the same incubator or crib) or a standard care group (cared for in separate incubators or cribs). Pain response (determined by the Premature Infant Pain Profile [PIPP]) and time to return to physiologic baseline parameters were compared between groups with adjustment for the nonindependence of twin infants.
Maternal and infant characteristics were not significantly different between twin infants in the cobedding and standard care groups except for 5-minute Apgar <7 and postnatal age and corrected gestational age on the day of the heel lance. Mean PIPP scores were not different between groups at 30, 60, or 120 seconds. At 90 seconds, mean PIPP scores were higher in the cobedding group (6.0 vs 5.0, P = .04). Recovery time was shorter in the cobedding group compared with the standard care group, (mean = 75.6 seconds versus 142.1 seconds, P = .001). No significant adverse events were associated with cobedding. Adjustment for nonindependence between twins and differences in baseline characteristics did not change the results.
Cobedding enhanced the physiologic recovery of preterm twins undergoing heel lance, but did not lead to lower pain scores.

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    ABSTRACT: With the increased birth rate of twins during the recent decades and improved prognosis of preterm infants, there is a need to explore measures that could optimise their growth and neurodevelopmental outcomes. It has been postulated that co-bedding simulates the twins' intrauterine experiences in which co-regulatory behaviours between the twins are observed. These behaviours are proposed to benefit the twins by reducing their stress, which may promote growth and development. However, uncertainties exist on the benefit-risk profile of co-bedding in practice. We aimed to assess the effects of co-bedding on growth, and other clinically relevant physiological and neurodevelopmental outcomes for stable preterm twins. We used the standard search strategy of the Cochrane Neonatal Review Group (CNRG). We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2012, Issue 7), MEDLINE (via PubMed), EMBASE (hosted by EBCHOST), CINAHL and references cited in our shortlisted articles using keywords and MesH headings, up to July 2012. We included randomised controlled trials with randomisation either at the level of each twin pair and/or at the level of neonatal unit. We excluded cross-over studies. We extracted data using the standard methods of the CNRG. Two review authors independently assessed the relevance and risk of bias of the retrieved records. We contacted the authors of the included studies if important information was missing from their published papers. We expressed our results using risk ratio (RR) and mean difference (MD) where appropriate with their 95% confidence intervals (CIs). We adjusted the unit of analysis from individual infants to twin pairs by averaging the measurement for each twin pair (continuous outcome) or by counting the outcome as positive if any of the twins developed the outcome (dichotomous outcome). Five studies met the inclusion criteria; however, data were only available for analysis in four studies. Four of the five included studies were small and had significant limitations in design. As each study reported the outcomes differently, data for most of the outcomes were effectively contributed by a single study. There were no differences between co-bedded twins and twins that received separate care in the rate of weight gain (MD 0.20 grams/kg/day, 95% CI: -1.60 to 2.00), apnoea, bradycardia and desaturation (A/B/D) episodes (RR: 0.85, 95% CI: 0.18 to 4.05; 1 study), length of hospital stay (MD -4.90 days, 95% CI: -35.23 to 25.43) and infection rates (typical RR: 0.84, 95% CI: 0.30 to 2.31; 3 studies). There were also no differences in parental perceptions of care. Co-bedded twins appeared to spend more time crying, but they also seemed to spend more time in quiet sleep. There was low or very low quality of evidence across all the outcomes. There was insufficient evidence on the benefits and harms of co-bedding stable preterm twins to make any recommendation in practice. There is a need for future studies that are adequately powered to detect clinically important differences in growth and neurodevelopment. Such studies should also assess harms including infections and medication errors, and caregiver satisfaction.
    Cochrane database of systematic reviews (Online) 01/2012; 12(12):CD008313. DOI:10.1002/14651858.CD008313.pub2 · 5.94 Impact Factor
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    ABSTRACT: Skin-to-skin care (SSC), otherwise known as Kangaroo Care (KC) due to its similarity with marsupial behaviour of ventral maternal-infant contact, is one non-pharmacological intervention for pain control in infants. The primary objectives were to determine the effect of SSC alone on pain from medical or nursing procedures in neonates undergoing painful procedures compared to no intervention, sucrose or other analgesics, or additions to simple SSC such as rocking; and the effects of the amount of SSC (duration in minutes) and the method of administration (who provided the SSC, positioning of caregiver and neonate pair).The secondary objectives were to determine the incidence of untoward effects of SSC and to compare the SSC effect in different postmenstrual age subgroups of infants. The standard methods of the Cochrane Neonatal Collaborative Review Group were used. Databases searched in August 2011: Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library); Evidence-Based Medicine Reviews; MEDLINE (1950 onwards); PubMed (1975 onwards); EMBASE (1974 onwards); CINAHL (1982 onwards); Web of Science (1980 onwards); LILACS database (1982 onwards); SCIELO database (1982 onwards); PsycInfo (1980 onwards); AMED (1985 onwards); Dissertation-Abstracts International (1980 onwards). Searches were conducted throughout September 2012. Studies with randomisation or quasi-randomisation, double or single-blinded, involving term infants (> 37 completed weeks postmenstrual age (PMA)) to a maximum of 44 weeks PMA and preterm infants (< 37 completed weeks PMA) receiving SSC for painful procedures conducted by doctors, nurses, or other healthcare professionals. The main outcome measures were physiological or behavioural pain indicators and composite pain scores. A weighted mean difference (WMD) with 95% confidence interval (CI) using a fixed-effect model was reported for continuous outcome measures. We included variations on type of tissue-damaging procedure, provider of care, and duration of SSC. Nineteen studies (n = 1594 infants) were included. Fifteen studies (n = 744) used heel lance as the painful procedure, one study combined venepuncture and heel stick (n = 50), two used intramuscular injection, and one used 'vaccination' (n = 80). The studies that were included were generally strong and free from bias.Eleven studies (n = 1363) compared SSC alone to a no-treatment control. Although 11 studies measured heart rate during painful procedures, data from only four studies (n = 121) could be combined to give a mean difference (MD) of 0.35 beats per minute (95% CI -6.01 to 6.71). Three other studies that were not included in meta-analyses also reported no difference in heart rate after the painful procedure. Two studies reported heart rate variability outcomes and found no significant differences. Five studies used the Premature Infant Pain Profile (PIPP) as a primary outcome, which favoured SCC at 30 seconds (n = 268) (MD -3.21, 95% CI -3.94 to -2.48), 60 seconds (n = 164) (MD -1.85, 95% CI -3.03 to -0.68), and 90 seconds (n = 163) (MD -1.34, 95% CI -2.56 to -0.13), but at 120 seconds (n = 157) there was no difference. No studies provided findings on return of heart rate to baseline level, oxygen saturation, cortisol levels, duration of crying, and facial actions that could be combined for analysis.Eight studies compared SSC to another intervention with or without a no-treatment control. Two cross-over studies (n = 80) compared mother versus other provider on PIPP scores at 30, 60, 90, and 120 seconds with no significant difference. When SSC was compared to other interventions, there were not enough similar studies to pool results in an analysis. One study compared SSC with and without dextrose and found that the combination was most effective and that SSC alone was more effective than dextrose alone. Similarly, in another study SSC was more effective than oral glucose for heart rate but not oxygen saturation. SSC either in combination with breastfeeding or alone was favoured over a no-treatment control, but was not different to breastfeeding. There were not enough participants with similar outcomes and painful procedures to compare age groups or duration of SSC. No adverse events were reported in any of the studies. SSC appears to be effective, as measured by composite pain indicators and including both physiological and behavioural indicators, and safe for a single painful procedure such as a heel lance. Purely behavioural indicators tended to favour SSC but there remains questionable bias regarding behavioural indicators. Physiological indicators were typically not different between conditions. Only two studies compared mother providers to others, with non-significant results. There was more heterogeneity in the studies with behavioural or composite outcomes. There is a need for replication studies that use similar, clearly defined outcomes. New studies examining optimal duration of SSC, gestational age groups, repeated use, and long-term effects of SSC are needed.
    Cochrane database of systematic reviews (Online) 01/2014; 1(1):CD008435. DOI:10.1002/14651858.CD008435.pub2 · 5.94 Impact Factor
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    ABSTRACT: Background The purpose of this trial was to determine whether cobedding of preterm twins has analgesic effects during heel lancing or not. Methods One hundred premature twins (50 sets) born between 26 weeks' and 34 weeks' gestation undergoing heel blood sampling were randomly assigned into two groups: the cobedding group (receiving care in the same incubator) and the standard care group (receiving care in separate incubators). Pain was assessed using the premature infant pain profile score. Duration of crying was measured after heel blood sampling, and salivary cortisol was measured prior to and after heel blood sampling. Results Infants in the standard care group cried for a longer time during heel lancing than those in the cobedding group (42.6 ± 19.8 seconds vs. 36.4 ± 21.7 seconds, p = 0.03). The mean premature infant pain profile score after heel lancing was significantly higher in the standard care group (9.8 ± 2.6 vs. 8.06 ± 2.8, p = 0.002). The mean salivary cortisol after heel lancing was also significantly higher in the standard care group (24.3 ± 7.4 nmol/L vs. 20.8 ± 7.4 nmol/L, p = 0.02). No significant adverse effects were seen with cobedding. Conclusion Cobedding is a comforting measure for twin premature infants during heel lancing, which can be performed without any significant adverse effects.
    Pediatrics & Neonatology 08/2014; DOI:10.1016/j.pedneo.2013.11.008 · 0.88 Impact Factor