Avanços na medicina e o desenvolvimento tecnológico têm contribuído para o aumento na sobrevida dos prematuros, no entanto, em virtude da sofisticação dos recursos, um maior número de procedimentos invasivos se faz necessário, incluindo a dor como um custo à sobrevida desses pacientes. O objetivo deste estudo foi testar a efetividade do contato pele a pele na diminuição das respostas comportamentais e fisiológicas de dor no prematuro, durante a punção de calcâneo para coleta do Teste do Pezinho. Trata-se de um estudo analítico-experimental randomizado, realizado na unidade de cuidado intermediário neonatal de um hospital universitário de Ribeirão Preto - SP. A amostra constituiu-se de 59 prematuros submetidos à coleta do Teste do Pezinho, divididos aleatoriamente em dois grupos: experimental (n=31), submetido ao contato materno pele a pele por 15 minutos antes e durante todo o procedimento, e controle (n=28) cujos bebês eram mantidos no berço ou incubadora durante todo o procedimento. O projeto foi aprovado pelo Comitê de Ética em Pesquisa da instituição, e o Termo de Consentimento Livre e Esclarecido foi firmado com as mães ou responsáveis pelos prematuros. As variáveis comportamentais (mímica facial, estado de sono e vigília e choro) foram registradas continuamente pela filmagem por uma câmera durante a coleta de dados. A variável fisiológica (freqüência cardíaca) foi mensurada por um monitor cardíaco. A coleta foi dividida em sete períodos: basal, tratamento, antissepsia, punção, ordenha, compressão e recuperação. Como não se comprovou a normalidade das variáveis quantitativas, fez-se a comparação entre os dois grupos utilizando-se o teste não-paramétrico para duas amostras independentes, Mann-Whitney. Para as variáveis qualitativas, utilizou-se o Qui-Quadrado ou Teste Exato de Fisher. Na comparação dos resultados dos escores do Neonatal Facing Coding System (NFCS), do estado de sono e vigília e da média da freqüência cardíaca intra-sujeitos e entregrupos, utilizou-se a ANOVA com medidas repetidas. Nas comparações do NFCS entre os grupos, utilizou-se a ANCOVA e estratificação direta. Os valores médios do NFCS foram inferiores no grupo experimental em todos os períodos com diferença estatisticamente significativa nos períodos de punção e ordenha em comparação ao grupo controle, mesmo ao se controlar a idade corrigida, idade pós-natal, experiência prévia de dor e o sexo. O choro foi o estado de sono e vigília mais incidente na punção e ordenha em ambos os grupos, sendo que, na ordenha, os bebês do grupo controle permaneceram chorando em maior proporção do que no experimental (85,7 vs 58,1%). Na recuperação, 71,0% do grupo experimental estavam em sono profundo em comparação com 21,4% no controle. O tempo médio de choro diferiu significativamente entre os grupos, sendo maior no controle. Houve elevação da freqüência cardíaca como resposta ao procedimento, mas a diferença não foi estatisticamente significativa entregrupos, todavia no grupo experimental houve retorno próximo ao valor médio basal na recuperação; no controle manteve-se acima de 160 bpm da antissepsia à recuperação. Comprovou-se a efetividade do contato pele a pele no alívio da dor em prematuros, constituindo-se em medida simples e natural, sem custos adicionais, podendo ser aplicada em diversas situações de dor aguda. / Advances in medicine and technological development have contributed to increase in preterm infants? survival. However, due to resource sophistication, more invasive procedures are needed, including pain as a price to pay for these patients? survival. This research aimed to test the efficacy of skin-to-skin contact to decrease preterm infants? behavioral and physiological pain response during heel lancing to collect the PKU test. This analytic randomized trial was carried out at the intermediary neonatal care unit of a university hospital in Ribeirão Preto - SP. The sample consisted of 59 preterm infants who were submitted to PKU test collection, randomly divided in two groups: experimental (n=31), submitted to skin-to-skin contact with the mother for 15 minutes before and during the entire procedure, and control (n=28), whose babies were held in the cot or incubator during the entire procedure. The project was approved by the institutional Research Ethics Committee, and the mothers or responsibles for the infants signed the Free and Informed Consent Term. The behavioral variables (facial mimics, sleep-wake state and cry response) were continuously recorded by a camera during data collection. The physiological variable (heart frequency) was measured by a heart monitor. Data collection was divided in seven periods: baseline, treatment, antisepsis, heel lancing, heel squeezing, compression and recovery. As the normality of the quantitative variables was not proved, the two groups were compared, using Mann-Whitney?s nonparametric test for two independent samples. For the qualitative variables, Chi-Square or Fisher?s Exact Test was applied. Variance analysis with repeated means was used to compare NFCS scores, sleep-wake state and mean heart frequencies within and between subjects. Covariance analysis and direct stratification were used to compare NFCS scores between the groups. Mean NFCS scores were lower in the experimental group across all periods, with statistically significant differences during heel lancing and squeezing in comparison with the control group, even when controlling for corrected age, postnatal age, previous pain experience and gender. Crying was the most incident sleep-wake state during lancing and squeezing in both group. During squeezing, babies in the control group continued crying longer than in the experimental group (85.7 vs. 58.1%). During recovery, 71.0% of the experimental group was in deep sleep, against 21.4% of controls. Mean crying time differed between the groups, with statistical significance, and was longer in the control group. Heart frequencies increased in response to the procedure, but intergroup differences were not statistically significant. However, during recovery, babies in the experimental groups returned close to mean baseline levels, while heart rates in the control group continued above 160 bpm from antisepsis until recovery. Results prove the efficacy of skin-to-skin contact proved to be effective for pain relief in preterm infants, constituting a simple and natural measure, without additional costs and easily applicable in different acute pain situations.

Avanços na medicina e o desenvolvimento tecnológico têm contribuído para o aumento na sobrevida dos prematuros, no entanto, em virtude da sofisticação dos recursos, um maior número de procedimentos invasivos se faz necessário, incluindo a dor como um custo à sobrevida desses pacientes. O objetivo deste estudo foi testar a efetividade do contato pele a pele na diminuição das respostas comportamentais e fisiológicas de dor no prematuro, durante a punção de calcâneo para coleta do Teste do Pezinho. Trata-se de um estudo analítico-experimental randomizado, realizado na unidade de cuidado intermediário neonatal de um hospital universitário de Ribeirão Preto - SP. A amostra constituiu-se de 59 prematuros submetidos à coleta do Teste do Pezinho, divididos aleatoriamente em dois grupos: experimental (n=31), submetido ao contato materno pele a pele por 15 minutos antes e durante todo o procedimento, e controle (n=28) cujos bebês eram mantidos no berço ou incubadora durante todo o procedimento. O projeto foi aprovado pelo Comitê de Ética em Pesquisa da instituição, e o Termo de Consentimento Livre e Esclarecido foi firmado com as mães ou responsáveis pelos prematuros. As variáveis comportamentais (mímica facial, estado de sono e vigília e choro) foram registradas continuamente pela filmagem por uma câmera durante a coleta de dados. A variável fisiológica (freqüência cardíaca) foi mensurada por um monitor cardíaco. A coleta foi dividida em sete períodos: basal, tratamento, antissepsia, punção, ordenha, compressão e recuperação. Como não se comprovou a normalidade das variáveis quantitativas, fez-se a comparação entre os dois grupos utilizando-se o teste não-paramétrico para duas amostras independentes, Mann-Whitney. Para as variáveis qualitativas, utilizou-se o Qui-Quadrado ou Teste Exato de Fisher. Na comparação dos resultados dos escores do Neonatal Facing Coding System (NFCS), do estado de sono e vigília e da média da freqüência cardíaca intra-sujeitos e entregrupos, utilizou-se a ANOVA com medidas repetidas. Nas comparações do NFCS entre os grupos, utilizou-se a ANCOVA e estratificação direta. Os valores médios do NFCS foram inferiores no grupo experimental em todos os períodos com diferença estatisticamente significativa nos períodos de punção e ordenha em comparação ao grupo controle, mesmo ao se controlar a idade corrigida, idade pós-natal, experiência prévia de dor e o sexo. O choro foi o estado de sono e vigília mais incidente na punção e ordenha em ambos os grupos, sendo que, na ordenha, os bebês do grupo controle permaneceram chorando em maior proporção do que no experimental (85,7 vs 58,1%). Na recuperação, 71,0% do grupo experimental estavam em sono profundo em comparação com 21,4% no controle. O tempo médio de choro diferiu significativamente entre os grupos, sendo maior no controle. Houve elevação da freqüência cardíaca como resposta ao procedimento, mas a diferença não foi estatisticamente significativa entregrupos, todavia no grupo experimental houve retorno próximo ao valor médio basal na recuperação; no controle manteve-se acima de 160 bpm da antissepsia à recuperação. Comprovou-se a efetividade do contato pele a pele no alívio da dor em prematuros, constituindo-se em medida simples e natural, sem custos adicionais, podendo ser aplicada em diversas situações de dor aguda. / Advances in medicine and technological development have contributed to increase in preterm infants? survival. However, due to resource sophistication, more invasive procedures are needed, including pain as a price to pay for these patients? survival. This research aimed to test the efficacy of skin-to-skin contact to decrease preterm infants? behavioral and physiological pain response during heel lancing to collect the PKU test. This analytic randomized trial was carried out at the intermediary neonatal care unit of a university hospital in Ribeirão Preto - SP. The sample consisted of 59 preterm infants who were submitted to PKU test collection, randomly divided in two groups: experimental (n=31), submitted to skin-to-skin contact with the mother for 15 minutes before and during the entire procedure, and control (n=28), whose babies were held in the cot or incubator during the entire procedure. The project was approved by the institutional Research Ethics Committee, and the mothers or responsibles for the infants signed the Free and Informed Consent Term. The behavioral variables (facial mimics, sleep-wake state and cry response) were continuously recorded by a camera during data collection. The physiological variable (heart frequency) was measured by a heart monitor. Data collection was divided in seven periods: baseline, treatment, antisepsis, heel lancing, heel squeezing, compression and recovery. As the normality of the quantitative variables was not proved, the two groups were compared, using Mann-Whitney?s nonparametric test for two independent samples. For the qualitative variables, Chi-Square or Fisher?s Exact Test was applied. Variance analysis with repeated means was used to compare NFCS scores, sleep-wake state and mean heart frequencies within and between subjects. Covariance analysis and direct stratification were used to compare NFCS scores between the groups. Mean NFCS scores were lower in the experimental group across all periods, with statistically significant differences during heel lancing and squeezing in comparison with the control group, even when controlling for corrected age, postnatal age, previous pain experience and gender. Crying was the most incident sleep-wake state during lancing and squeezing in both group. During squeezing, babies in the control group continued crying longer than in the experimental group (85.7 vs. 58.1%). During recovery, 71.0% of the experimental group was in deep sleep, against 21.4% of controls. Mean crying time differed between the groups, with statistical significance, and was longer in the control group. Heart frequencies increased in response to the procedure, but intergroup differences were not statistically significant. However, during recovery, babies in the experimental groups returned close to mean baseline levels, while heart rates in the control group continued above 160 bpm from antisepsis until recovery. Results prove the efficacy of skin-to-skin contact proved to be effective for pain relief in preterm infants, constituting a simple and natural measure, without additional costs and easily applicable in different acute pain situations.

Family-centered care (FCC) is considered the gold standard for care delivery in the Neonatal Intensive Care Unit (NICU). However, there are challenges with the implementation of FCC in practice and there is limited literature about how to tailor this approach for specialized NICU populations. To explore FCC for surgical neonates in the NICU, the concept was explored using Roger’s evolutionary concept analysis. Results illustrate that FCC in the NICU is a philosophy or care, rather than a set of interventions. The subsequent cross-sectional descriptive exploratory study showed that the surgical infants in our sample (n=11) received a limited amount of skin-to-skin care (median 0 mins/day) and parents reported challenges to being involved in their infant’s care. This thesis supports the challenges with the implementation of FCC in practice and both the need to consider multiple perspectives and the need for broader systemic change in order to support a FCC philosophy.

Bakgrund: År 1991 lanserade WHO och UNICEF "Baby Friendly Hospitals Initiative" (BFHI). Motivet var den nedåtgående amningsfrekvensen världen över och de konsekvenser som det medförde till exempel socialt och ekonomiskt. Till grund fanns innocentdeklarationen som bygger på att alla BB avdelningar skall följa "tio steg till lyckad amning. Målet med detta är att främja, stödja och skydda amningen. Forskning visar att amningsfrekvensen har sjunkit de senaste åren i Sverige. Syfte: Syftet var att undersöka nyblivna mödrars upplevelse av stöd i sin förberedelse och uppstart av amning i Kronobergs län och jämföra detta med mödrar vid tre andra kvinnokliniker (Blekinge län, södra Kalmar län och norra Kalmar län). Metod: Undersökningen har en kvantitativ ansats. Enkäter med totalt 35 frågor har delats ut till mödrar vid deras besök för efterkontroll på mödrahälsovården i Kronobergs län. En jämförelse har därefter gjorts med mödrars svar i norra Kalmar, södra Kalmar och Blekinge län. Resultat: I Kronobergs län ammade 74.4% helt vid efterkontrollen, det fanns en signifikant skillnad mellan de olika klinikerna (p=0.021). Majoriteten av kvinnorna på de olika klinikerna hade en positiv inställning till amning under graviditeten. Större delen av kvinnorna svarade att de hade haft hudkontakt direkt efter förlossningen, men tiden för hudkontakt varierade. I Kronobergs län rapporterade majoriteten av kvinnorna att de hade haft hudkontakt i mindre än 60 min efter förlossningen. Gemensamt för orterna är att de flesta kvinnor svarat att hudkontakten med barnet avslutades när barnet skulle mätas eller vägas (47,2% i Kronobergs län). Det fanns skillnader i amningsstöd från personal mellan de olika klinikerna. I Kronobergs län var det 12.5% av kvinnorna som hade önskat mer hjälp från personalen på BB, medan det i norra Kalmar var 20.8%. Det var nästan 40% av alla barn som hade blivit tillmatade med bröstmjölksersättning på BB och hälften av dessa utan medicinsk indikation. Slutsats: De tio stegen till lyckad amning följs av de fyra klinikerna, men i vissa av stegen finns brister i hur de följs. Hudkontakt bör prioriteras efter förlossning. För att kunna ge kvinnan ett optimalt amningsstöd bör insatser tillsättas på MHV, BB och på BHV. Tillmatningsrutiner på BB bör ses över på alla fyra kliniker. / Background: In 1991, launched the WHO and UNICEF ' Baby Friendly Hospital Initiative " (BFHI). The subject was the downward frequency of breastfeeding worldwide and the consequences that it brought such as socially and economically. The basis was the "innocenti declaration" which is based on that all maternity wards must follow the "ten steps to successful breastfeeding". The goal of this is to promote, support and protect breastfeeding. Research shows that the frequency of breast feeding has fallen in Sweden the last couple of years. Purpose: The aim was to examine expectant mothers' experience of support in their preparation and start-up of breastfeeding in Kronoberg county and compare this with the mothers at three other women's clinics (Blekinge, southern Kalmar county and northern Kalmar). Method: The study has a quantitative approach. Surveys with a total of 35 questions were distributed to mothers during visits to antenatal care for the post in Kronoberg County. A comparison was then made with the mothers answers at north Kalmar, south Kalmar and Blekinge county. Results: In Kronoberg breastfed 74.4% of the mothers completely at the control, there was a significant difference between the clinics (p = 0.021). The majority of women of different clinics had a positive attitude to breastfeeding during pregnancy. Most of the women said they had had skin contact immediately after birth, although the time of skin contact varied. In Kronoberg County reported the majority of women reported that they had had contact with the skin in less than 60 minutes after birth. Common for the clinics is that most women responded that skin contact with the baby ended when the child would be weighed or measured (47.2% in Kronoberg County). There were differences in breastfeeding support from staff between the clinics. In Kronoberg County, it was 12.5% of women who had wanted more help from the staff at the maternity ward, while in northern Kalmar was 20.8%. It was almost 40% of children who had become fed with formula milk in the maternity ward and half of those without a medical indication. Conclusion: The ten steps to successful breastfeeding are followed by the four departments, but in some of the steps are flaws in how they are implemented. Skin contact should be prioritized after childbirth. In order to give the woman an optimal breastfeeding support, efforts should be put on antenatal care, maternity wards and at the child health care. The feeding routines on the maternity ward should be reviewed at all four clinics.

Bakgrund: KMC (kangaroo mother care) är en metod där det prematura barnet ligger hud- mot-hud med en förälder. Metoden har tidigare visats vara bra för både barnet och modern. Syfte: Syftet är att, i jämförelse med traditionell vård, beskriva effekten av känguruvård på det prematurt födda barnet både gällande fysiska effekter och barnets anknytning till föräldrarna. Metod: Litteraturöversikt med kvantitativa studier. I studien ingick 12 artiklar varav 10 hade RCT (Randomiserad kontrollerad studie) som metod. En kvasiexperimentell artikel och en överkorsningsstudie analyserades också till resultatet. Resultat: Resultaten visade att KMC kan reducera smärta hos prematura barn vid provtagning, vilket visas genom att barnet gråter mindre och grimaserar mindre i jämförelse med barn som enbart fått traditionell vård. Vid brukandet av KMC sjunker kortisolnivåerna hos barnet, speciellt över tid. Detta betyder att barnet blir mindre stressat. KMC bidrar också till en snabbare tillväxt och stabilare parametrar i form av hjärtfrekvens, saturation och medeltemperatur. Det har även visat sig att KMC kan underlätta och påskynda anknytningen mellan modern och barnet. Alla skillnader sågs vid jämförelse med traditionell vård. Slutsats: KMC har positiva effekter på fysiska parametrar och verkar påverka anknytningen positivt mellan förälder och barn. De fysiska parametrarna blir mer stabila och får bättre värden vid brukandet av KMC. Slutsatsen är därför att KMC bör rekommenderas som metod. Nyckelord: Känguruvård, hud-mot-hudvård, prematur, anknytning, fysiska effekter / Background: KMC (kangaroo mother care) is a method were the premature child lay skin to skin with a parent. The method has earlier shown to be good for both the child and the mother. Aim: The aim was to, in comparison to traditional care, describe the effect of kangaroo mother care on the premature child both including physical effects and the childs attachment to the parents. Method: Litterature overview with quantitative design. The study included 12 articles were 10 of them had RCT (Randomized controlled trial) as design. One qvasiexperimental article and one crossover trial were also analyzed. Result: The results showed that KMC can reduce pain in preterm infants during painful procedures, in comparisson to traditional care. This was evident as the baby was crying and grimacing less. By using the KMC method the babys’ cortisol level decreased, especially over time. This indicates that the baby was less stressed when KMC was used compared to when it was not. KMC also contributed to a faster growth in length and weight, more stabile parameters as heart rate, saturation and mean temperature. It was also shown that KMC can facilitate and favour attatchment between the mother and the infant. All differences were shown when compared to traditional care. Conclusion: KMC have positive physical effects on the premature child and affect the attachment between parent and child. The physical parameters become more stabile and better while using KMC. The conclusion is that KMC should be recommended as a method. Key Words: Kangaroo mother care, skin-to-skin care, premature, attachment, physical effects

Kangaroo Mother Care (KMC) is an evidence-based intervention, recommended by the World Health Organization, with the potential to prevent neonatal deaths and morbidity among low-birthweight and preterm babies. In Bangladesh, where the number of neonatal deaths is high, KMC is identified as a priority intervention to be scaled up in the country. Our aim was to explore the experiences of caregivers and healthcare providers (HCPs) of KMC in Bangladesh. We conducted semi-structured interviews in two hospitals in Dhaka, where KCM service was provided. In Study I, we interviewed fifteen caregivers. The results showed conducive conditions for caregivers to perform KMC at the hospital and at home, but support is needed from both healthcare providers and their families. Caregivers felt empowered and motivated when they observed improvements in the child's well-being. However, there are challenges to KMC implementation due to the struggle to keep the baby skin-to-skin, pain after caesarean section, delayed initiation of KMC, and routines that promote an initial separation between the mother and baby. In Study II, we interviewed eleven HCPs. The results showed that HCPs experienced KMC as a continuous process that requires both support and counselling, adapted to caregivers’ needs. Commitment, supervision, and training are necessary. However, there are structural conditions that challenge KMC implementation, including clinical routines that promote the initial separation of the mother and baby, staff shortages, and incomplete follow-up. In conclusion, the findings from this exploratory research can inform the design of interventions for scaling up KMC in Bangladesh. Caregivers' and HCPs' experiences show that continuous support, counselling, and family involvement are essential in the care, and that providing KMC empowers caregivers. Their experiences also indicate that KMC is sub-optimally implemented due to structural conditions and routines that need to be addressed to scale up KMC in the country by avoiding the initial separation of mother and baby, meeting the mothers' needs for care and support, and strengthening the follow-up. Our results also suggest a need to update clinical practices in line with the new WHO recommendations. / <p></p><p></p><p></p>