Sharon Trotter RM BSc
Midwife, Breastfeeding Consultant and Neonatal Skincare Advisor
Skin-to-Skin Contact: a realistic treatment for Transient Tacypnea of the newborn?
The full reference for this draft paper which was published in RCM Midwives Journal is: Trotter S (2005). Skin-to skin contact: therapy or treatment? RCM Midwives Journal 8(5): 202-3.
This Paper will examine the case study of a neonate suffering from Transient Tachypnea of the Newborn (TTN) called Adam. In particular it will focus on the beneficial effects of Skin-to-Skin Contact (SSC) as a form of non-invasive therapy for the neonate that is compromised but not unstable. It will further address the possibility that low risk infants can be treated within a holistic framework, whereby Midwives and Advanced Neonatal Nurse Practitioners (ANNPs) become the lead carers within an area dominated by clinicians. This holistic approach to care involves an inter-relationship between mind, body and spirit (Koehn 2000) and does not involve the loss of control of any party. The beneficial effects of these non-invasive therapies combine to promote physiological well-being for the neonate (Anderson 2004), whilst involving parents throughout. This not only avoids exclusion from decision-making, but also increases parental satisfaction, by allowing participation, which leads to a positive outcome for all.
Adam was born at 41 weeks gestation following a short labour but prolonged second stage due to persistent-occipito-posterior (POP) position. The infant weighed 5.5kgs and initial APGAR scores of 9/1 & 9/5 alongside a normal first examination, suggested that all was well. SSC was initiated immediately and breastfeeding was successful. Within 8 hours of birth Adam developed a raised heart/respiration rate but as the mother was an experienced midwife, she was happy to observe her baby and carry out constant SSC in the hope that this would regulate the infants vital signs (Anderson 2004). Although slightly agitated, the infant demand fed from the breast. By 24 hrs of age the heart rate had increased to 140-160 bpm and the respiration rate was 88, combined with mild chest recession and grunting. Body temperature remained stable and there was no cyanosis or nasal flaring. The paediatric Senior House Officer was asked to review the case and it was decided that, although the infant was indeed mildly distressed, he could remain with his mother, whilst continuing with SSC for a further period of observation on the postnatal ward. By the next review, at 36 hours of age both the heart and respiration rate had returned to normal and the infant was declared fit. There were no further problems.
Transient Tachypnea is the commonest cause of respiratory distress in the neonate. The term TTN was first used by Avery et al (1966) to describe the respiratory disease similar but distinct from respitaory distress syndrome. It is attributed to the delayed absorption of fetal lung fluid and is also known as Wet Lung, Retained Lung Fluid and Type 2 Respiratory Distress Syndrome. The incidence is 1-2% of all newborns (Gomella 1994).
The differential diagnosis of TTN as against Respiratory Distress Syndrome (RDS) is made on the basis of L/S ratio (Lecithin & Sphingomyelin), estimated on amniotic fluid or gastric aspirate sampled in the first hour of life and chest x-rays (Tudehope & Smyth 1979). Other distinct differences between TTN and RDS have been observed and it is important for professionals to be aware of these, to avoid misdiagnosis. TTN exhibits, in particular, over inflation of the lungs, mild acidosis and cardiomegaly. Although worrying, TTN is usually self-limiting, whereas RDS has the potential to cause serious long-term complications (Halliday et al 1989). Treatment, if required, comprises oxygen therapy and rarely ventilation.
Once delivered, Adam was placed directly on his mother’s chest for a period of SSC. This quickly calmed the traumatised infant.
Due to the increased surface area to body mass ratio, a baby is at risk from loosing heat due to convection, conduction, evaporation and radiation. It also has to rely on stores of ‘brown fat’, which can be quickly and easily metabolised, to maintain body heat (Sweet 1997). This is known as non-shivering thermoregulation.
Whilst in the womb, antibodies pass from mother to baby via the placenta. This confers passive immunity for the first six months of life against infections that the mother has become immune to in the past. Soon after birth the baby is colonised by microorganisms on the skin, umbilical cord, respiratory tract and gastrointestinal tract. The biggest danger to the neonate is from cross infection, which is why 24-hour rooming-in is now advocated. This cuts down on the number of handlers, which in turn reduces the risk of nosocomial infection (Anderson 2004).
At birth, an infant must be able to suck, swallow, digest, absorb and excrete in order to grow. The obvious food of choice is breast milk because it is easy to digest and provides each individual baby with the perfect combination of dietary requirements. The benefits are so comprehensive that the World Health Organisation (WHO) recommends exclusive breastfeeding for the first six months of life (WHO 2001). If breast milk or expressed breast milk from a milk bank is not available then a milk substitute can be given. If a baby is too sick or premature to feed, naso-gastric or intra-venous feeding may be required until the infant can maintain a stable blood sugar and is well enough to initiate feeding. Due to the traumatic second stage of labour, he was visibly distressed so the comfort achieved by breastfeeding, coupled with the closeness of SSC combined to calm the infant. Adam suffered TTN during the first 36 hours of life. This would have lead to a sharp rise in his energy requirements, due to his increased heart and respiration rates. This, added to the macrosomia, would have put him at risk of developing hypoglycaemia (Roberton 1996). However, due to the stabilising effect of SSC, with regard to blood sugar levels (Anderson 2004), Adam remained asymptomatic, obviating any need for invasive blood tests. [back to top]
The stressful effects placed upon the neonate, during the process of labour and birth, cannot be underestimated. The transition from a dark, warm, secure environment, into a bright, noisy and relatively cold world must be shocking and the care given to mother and baby must reflect this. The development of respiratory distress will be less likely if physiological and psychological stressors can be kept to a minimum. Much work has been done on the effects of routine care within neonatal units and how it can act as a stress factor (Peters 1992). It could be argued that a balance needs to be struck between the benefits and potential risks of proposed treatments.
This simply means placing a newborn baby prone on the mother’s chest at birth or soon after. The rationale comes from animal studies that show the importance of closeness between mother and baby, which in turn leads to successful suckling and hence survival (Alberts1994). Sensory stimulation involving warmth, touch and smell are an extremely powerful vagal stimulant causing oxytocic release, which in turn raises the skin temperature of the breast, decreasing anxiety, increasing calmness and enhancing parental behaviours (Uvnas-Moberg 1998). Recent work carried out by Suzanne Colson (2003) has also looked into the subject of ‘biological nurturing’. This looks at the instinctive ways in which women and babies respond to each other whilst breastfeeding giving us an important insight into the mother/baby relationship.
Although SSC should ideally occur between mother and baby, there is evidence to suggest it can be just as beneficial when carried out between siblings (Lutes 1996). This American study documented the amazing results after placing twins together in cots, which lead to immediate and consistent cessation of unstable symptoms. This is already widespread in Europe and is encouraged once the infants are discharged.
The physiological and psychological responses of the neonate resulting from treatments in the NNU have demonstrated that they cannot distinguish between pleasant and unpleasant stimuli (Peters 1992). The machines used to care for these neonates also fail to distinguish between the subtleties of these responses. Ironically, the care we give to treat and protect the vulnerable infant may well, on occasions, be counter-productive.
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|© Sharon Trotter 2013|