While constituting a well functioning interface with the aqueous environment in utero, the skin offers a poor barrier after very preterm birth. As a result, transepidermal water loss (TEWL) is high, a fact which has important clinical consequences in these infants. To investigate the transport of water through perinatal skin and the potential role of aquaporin (AQP), a water channel protein, in this process, we determined TEWL in a group of extremely preterm infants, and in an experimental rat model we analyzed the expression and distribution of AQP in perinatal skin in relation to TEWL, skin surface hydration and water content. The effects of antenatal corticosteroids (ANS) and of restricted intake of fluids and nutrients on barrier characteristics of the perinatal skin and its AQP expression were also studied. In infants born at 24 and 25 weeks of gestation TEWL was very high in the first days after birth and decreased with increasing postnatal age. At a postnatal age of 4 weeks, TEWL was still twice as high as previously reported in infants born at a gestational age of 25-27 weeks and four times higher than in infants born at term. In the rat model, immunohistochemical analysis revealed that AQP1 and AQP3 are abundantly expressed in the skin. AQP1 was expressed exclusively in dermal capillaries and AQP3 in basal layers of the epidermis. AQP1 and AQP3 mRNA as assessed by semiquantitative RT-PCR was higher in fetal than in adult skin. As in infants, TEWL and skin surface hydration were inversely related to gestational age in the rat. In preterm rat pups exposed to ANS, TEWL and skin surface hydration were lower than in unexposed controls, and AQP3 expression was selectively induced by ANS. In term newborn rat pups, restriction of fluid and nutrient intake resulted in a higher skin water content and higher TEWL early after birth, while at an age of 7 days TEWL was lower in fasting rat pups than in controls, although skin water content was still higher. To conclude, TEWL is very high in extremely preterm infants early after birth and then decreases at a slower rate than previously reported for a group of slightly more mature infants. This is the first time that the distribution and gene expression of AQP1 and AQP3 have been demonstrated in perinatal skin. The localization and expression of AQP in the skin might indicate that these water channels are involved in the regulation of skin hydration and transepidermal water transport in the fetus and newborn infant.

The neonatal period represents a critical window of increased neurodevelopmental plasticity in the immature nervous system. Unlike other sensory modalities, which require appropriate stimulation for proper development, maturation of nociceptive circuitry in neonates typically occurs in the absence of noxious stimulation. Premature infants, however, are routinely exposed to multiple invasive medical procedures during neonatal intensive care treatment, which are largely performed in the absence of anesthetics or analgesics. To date, it is largely unknown how exposure to early noxious insult during this time of increased plasticity alters the development of the CNS and influences future nociceptive responses. As previous studies examining the impact of neonatal inflammatory insult on adult nociceptive responses have been conducted primarily in males, the potential adverse effects in females are unknown. Furthermore, the biological mechanisms underlying neonatal insult-induced deficits in nociceptive processing have yet to be elucidated. Therefore, this dissertation addressed the following questions: (1) Does neonatal inflammatory insult differentially alter male and female baseline somatosensory thresholds and response to re-inflammation in adulthood?; (2) Are neonatal inflammation-induced deficits in nociceptive responsiveness mediated by a potentiation in endogenous opioid tone?; and (3) Does pre-emptive morphine analgesia attenuate the behavioral consequences of neonatal inflammatory insult? Collectively, these studies will provide valuable information about the long-term consequences of neonatal noxious stimulation in males and females, which may lead to improved understanding and prevention of the lasting effects of repeated invasive interventions in premature infants in the NICU.

Aim: To examine the reaction of extreme preterm infants with regarding to body temperature and transepidermal water loss during skin-to-skin care according to Kangaroo Mother Care (KMC) during the infant’s first week of life. Method: This was a descriptive quantitatively designed study, which was a pilot study within the framework of a larger project. Nine children, with a median gestational age of 24.91 weeks, were examined by measuring body temperature (axilla and skin temperature) as well as transepidermal water loss before, during and after KMC. Results: The study showed that skin temperature tended to rise during KMC, especially for those children who were nursed with KMC for more than 60 minutes. Eight out of nine children had, after completing KMC, a normal axilla temperature. As was expected, transepidermal water loss was elevated when measured both pre and post test. Despite this, the children showed normal body temperature. Conclusion: The results of the study support that KMC can create a micro-climate that, for at least one hour, makes it possible for even extreme preterm infants to maintain a body temperature within the normal range during their first week of life.

Infants born prior to the term of 36 gestation weeks and 6 days are considered preterm infants. The number of preterm infants in Lithuania amounts to 5 – 6% per year. The most significant health problems of such infants in the neonate period are caused by immaturity of the organs and their systems. Knowledge of a preterm infant’s psychomotoric development contributes to early notification of disorders, more effective composition of problem-orientated corrective programs and monitoring of development progress. According to the reference literature, early application of physical therapy enables recovery of as much as 50 percent of infants and improvement of the condition of the rest. The goal of this thesis is to determine within which group: in the preterm infants (extremely preterm (born within 25-30 gestation week) or very preterm infants (born within 31-36 gestation week)), physical therapy has major effect for the emergence time of motor function. The objectives of the thesis are as follows: 1. Comparison of emergence time of motor functions with regard to extremely preterm and very preterm infants within the same stage of corrected age. 2. Comparison of motor development of the extremely preterm and very preterm infant groups and within each separate group considering the gender aspect. 3. Comparison of motor development alternation of the extremely preterm and very preterm infant groups and within each separate group considering the aspect of applied surgical treatment... [to full text]

Neišnešioto naujagimio adaptacija ankstyvuoju naujagimystės laikotarpiu yra ypač svarbi tolesnei jo gyvenimo kokybei. Šiuo jautriu vystymosi laikotarpiu aplinkos sukeliamam stresui mažinti taikoma muzikos terapija. Tačiau jos poveikis raidai nėra iki galo aiškus, be to, naudojami įvairūs muzikos terapijos būdai. Labai mažo gimimo svorio naujagimių stimuliacija muzika turi būti adekvati dėl jų fiziologinio nebrandumo, todėl muziką jiems reikėtų pateikti kuo efektyvesniu būdu. Atliktas darbas siekiant įvertinti trumpalaikį ir ilgalaikį muzikos terapijos poveikį. Buvo palygintas gyvai atliekamų ir įrašytų lopšinių poveikis neišnešiotų naujagimių fiziologiniams rodikliams ir elgsenai bei vertinamas muzikos terapijos poveikis jų sveikimui ir tolesnei psichomotorinei raidai. Nustatyta, kad muzikos terapija ankstyvuoju adaptacijos laikotarpiu efektyviai veikia neišnešiotų naujagimių (iki 32 savaičių pomenstruacinio amžiaus) širdies veiklą ir elgseną, t.y. naujagimių miegas yra gilesnis. Gyvai atliekamos lopšinės neišnešiotus naujagimius ramina geriau nei įrašytos. Muzikos terapijos įtaka kraujo įsotinimui deguonimi yra nereikšminga. Ilgalaikio muzikos terapijos poveikio grupėje nustatyta tendencija, kad neišnešioti naujagimiai išvyksta iš stacionaro turėdami didesnį svorio prieaugį, palyginti su kontroline grupe. Reikšmingo poveikio kūdikio psichomotorinei raidai nenustatyta, tačiau pastebėta, kad muzikos terapija stiprina tėvų bendravimą su vaiku ir gali būti aktyviai... [toliau žr. visą tekstą] / Adaptation of a preterm infant in the early neonatal period plays a relevant role in his/her further life quality. Within this sensitive development period music therapy is used to reduce environmental stress. However, its effect on development is not explicit; moreover, music therapy methods vary. Music stimulation of very low birth weight infants should be adequate due to their physiological immaturity, thus, they should be exposed to music in the most efficient way. The work was performed to evaluate a short-term and long-term effect. It compared the effect of live and recorded lullabies on physiological factors and behaviour of preterm infants and evaluated the effect of music therapy on their recovery and further psychomotor development. Music therapy has been proved as efficiently influencing heart rate and behaviour of preterm infants (under 32 weeks’ postmenstrual age), i.e. their sleep was deeper. Live lullabies sooth preterm infants more efficiently that recorded ones. The effect of music therapy on blood saturation was insignificant. The group of long-term music therapy exposure revealed that preterm infants tend to be discharged from hospital with bigger weight gain, to compare with the control group. Significant effect on the psychomotor development in preterm infants was not established; however, music therapy was observed as strengthening parent-child relation and available for active application from neonatal period.

Kangaroo Mother Care (KMC) is an alternative model of care that prevents parent-infant separation when preterm infants need neonatal intensive care by skin-to-skin contact between infants and their parents. KMC is also a strategy that involves parents in their infants’ care and enables them to assume the responsibility for the care. Furthermore, KMC promotes parent-infant bonding and attachment. The overall aim of this thesis was to gain a deeper understanding and knowledge about parents’ capacity, willingness, and experiences of KMC and to which extent parents choose to use KMC throughout their infants' hospital stay. These studies were conducted in the NICUs at two Swedish university hospitals (NICU A and NICU B). Mothers of infants cared for at NICU A (n=17) answered a questionnaire about their experiences of KMC (Paper I). Twenty parents of infants cared for at NICU A recorded the duration of each KMC session during a period of 24 hours and the identity the KMC provider (Paper II). Seven fathers were interviewed about their experiences of KMC (Paper III) and 76 mothers and 74 fathers completed a questionnaire about what facilitated or rendered it difficult to perform KMC (Paper IV). The time of initiation of KMC and duration in minutes, and the identity of the KMC providers was recorded continuously during the infants’ (n=104) hospital stay: 83 mothers and 80 fathers also completed a questionnaire during their infants’ hospital stay (Paper V). This thesis provides new knowledge about parents’ practice of KMC, also continuously day and night, in a high tech NICU in an affluent society, with good resources for infant care in an incubator by trained staff. The accuracy of parents’ records of KMC were comparable to nurses’ records. The results indicate that parents want to be together with their infant in the NICU and be actively involved in the infants’ care. Although parents may experience KMC as exhausting and uncomfortable, they still prefer KMC to conventional neonatal intensive care as it supports their parental role. Early initiation of KMC after birth appears to result in a longer total duration of KMC during the infants’ hospital stay.

Background: Physiological studies have shown that many preterm infants and infants with chronic lung disease may suffer chronic hypoxaemia, which possibly leads to poor growth and development. Anecdotal reports indicate that there is a drive to increase the oxygen saturation target range to a higher level in these infants due primarily to perceived benefits derived from clinical experience and from uncontrolled observational studies of babies discharged on home oxygen. Objective The BOOST (Benefits Of Oxygen Saturation Targeting) trial is the first randomised trial to assess the long-term benefits and harms of two different oxygen saturation target ranges. Methods: BOOST was a multicentre, double blinded, randomised controlled trial that enrolled 358 infants born at less than 30 weeks� gestation who remained oxygen-dependent at 32 weeks postmenstrual age. They were randomly assigned to target either a functional oxygen saturation range of 91-94% (standard or control group) or 95-98% (higher or treatment group). The primary outcomes were growth and neurodevelopmental measures at 12 months corrected age. Secondary outcomes included length of hospital stay, retinopathy of prematurity, health service utilisation, parental stress, and infant temperament. Results: Prognostic baseline characteristics did not differ between the two groups. Mean birth weight and gestational age of enrolled infants was 917g and 26.5 weeks respectively. The rate of antenatal corticosteroid use was 83%.

The sensory-motor-oral (SMO) stimulation during Intensive Care Neonatal period has been proposed in order to facilitate the transition from gavage to oral feeding and thereby promote weight gain, breastfeeding and minimize the difficulties in the introduction of solid foods during childhood. Objective: To determine whether the SMO stimulation influence the infant growth and the introduction of complementary feeding in children under two years old born preterm. Methods: Cross-sectional study that included 16 children, born preterm, randomly subjected to a program of sensory-motor-oral stimulation during their neonatal period. The children were assessed by anthropometric measurements and nutritional status was evaluated using the indicators P/E, P/I and E/I, according to the National Center Health Statistics (NCHS). Results: There was no statistical difference between groups regarding the z-score values for P/E, P/I, and E/I. In both groups children were classified as well-nourished. The duration of breastfeeding was higher among children stimulated when compared with the control with an average of 67.5 days and 30 days, respectively. The main reasons for early weaning from breastfeeding were the refusal of the children and insufficient milk production. The introduction of complementary foods occurred in the early period for both groups with an average of 5.8 months for the GE and 5.4 months for the GC. Three children (37.5%) in the CG and two (25%) in GE had difficulties when started with solid foods but there was no statistically significant difference. Conclusion: Based on these results, we could not confirm the benefit of a SMO stimulation program on nutritional status and body composition of children born preterm at age 12 to 24 months. However, the SMO stimulation seems to have a beneficial influence on the duration of exclusive breastfeeding and the introduction of solid foods. / A estimulação sensório-motora-oral (SMO) durante a internação na Unidade de Terapia Intensiva Neonatal tem sido proposta com a finalidade de facilitar a transição da alimentação por sonda gástrica para a via oral e com isso favorecer o ganho de peso, o aleitamento materno e minimizar as dificuldades na introdução de alimentos sólidos no período da infância. Objetivo: Verificar se existe influência da estimulação SMO sobre o crescimento infantil e sobre as dificuldades durante o período de introdução da alimentação complementar, em crianças menores de dois anos de idade, nascidas prétermo, submetidas à estimulação SMO no período de internação hospitalar. Métodos: Amostra constituída de 16 crianças distribuídas em grupo estimulado (GE) e grupo controle (GC). Foram realizadas medidas antropométricas e o estado nutricional foi avaliado a partir dos indicadores peso/estatura (P/E), peso/idade (P/I) e estatura/idade (E/I), tendo como referência o National Center for Health Statistics (NCHS). Para análise do consumo alimentar foi aplicado um recordatório de 24 horas e um questionário estruturado com informações sobre hábitos alimentares. Resultados: Não houve diferença estatisticamente significante entre os grupos, GE e GC, em relação à média de valores do escore-z de P/E, P/I e E/I. De maneira geral, em ambos os grupos o estado nutricional encontravase eutrófico. Observou-se que o tempo de amamentação exclusiva foi em média de 67,5 dias para o GE e 30 dias para o GC. Os principais motivos para o desmame precoce foi a recusa das crianças e a produção insuficiente de leite. Como consequência, a introdução de alimentos complementares ocorreu em período precoce para ambos os grupos, em média de 5,8 meses para o GE e 5,4 meses para o GC. Três (37,5%) crianças do GC e duas (25%) do GE apresentaram dificuldades para iniciar a introdução de alimentos sólidos, no entanto, não foram encontradas diferenças estatísticas significativas. Conclusão: Com base nos resultados encontrados, não foi possível comprovar o benefício de um programa de estimulação SMO, realizado durante a internação em UTI Neonatal, sobre o estado nutricional e a composição corporal das crianças nascidas pré-termo, na faixa etária de 12 a 24 meses. No entanto, acredita-se que as crianças que receberam a estimulação SMO tenham sido beneficiadas no que diz respeito ao maior tempo de amamentação exclusiva e à ausência de dificuldades para a introdução de novos alimentos.

In extremely preterm infants, acute abdominal emergencies are fortunately less common with improving care. Spontaneous intestinal perforation and necrotizing enterocolitis are conditions where emergency surgery is most often needed. Conservative medical management and placement of temporary drain are often used in the initial management. Internal hernia (IH) is an uncommon cause of bowel obstruction in neonates, is difficult to diagnose and unfortunately are found only at autopsy. The presentation in preterm infants, distinction between these conditions, and the need for early diagnosis of IH are discussed.

Numerous scholars have reported that inconsistent incubator humidity in the neonatal intensive care unit (NICU) requires attention. Evidence synthesis was needed to assist the identification of optimal incubator humidity levels and duration to decrease transepidermal water loss (TEWL) and the potential for infection. The purpose of this doctoral project was to appraise and synthesize the evidence of preterm outcomes related to incubator humidity. The practice-focused question addressed what patient outcomes were impacted by incubator humidity level and duration in premature infants < 32 0/7 weeks cared for in the NICU. The foundation of this project was the Joanna Briggs Institute method for systematic reviews. Mefford’s theory of health promotion for the preterm infant was used to address the wholeness of the preterm infant’s body system. Evidence was classified using the Johns Hopkins evidence-based practice levels and quality of evidence. The search was conducted in 8 databases, and citation searching was used to identify 340 articles, 12 of which met the inclusion criteria. The evidence demonstrates that the practice of incubator humidity is warranted; however, it does not come without risks. Microbial growth was increased in high levels of incubator humidity. Unnecessary TEWL was prevented by lowering high levels of incubator humidity after the 1st week, improving skin barrier formation. Incubator humidity of 60%–70% in the 1st week was effective in preventing TEWL in infants born ≥ 26 weeks; however, future research is needed for infants < 26 weeks. When optimal levels and duration of incubator humidity are achieved, positive social change will occur from the improved outcomes of the smallest neonatal patients.