Sharon Trotter RM BSc

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.

Abstract

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.

Case Study
Transient Tachypnea of the Newborn (TTN)
Care at birth
Thermoregulation
Infection control
Nutrition
Psychological stability
Skin-to-Skin Contact (SSC)
Variations on SSC
Conclusion
Key points
References

Case Study

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.
Had this infant been separated from his mother and transferred to the potentially stressful environment of the Neonatal Unit (NNU), it is possible that his condition would have deteriorated further, necessitating invasive procedures (Peters 1992). The positive outcome suggests that, in certain borderline cases, it may be wise to instigate a period of observed SSC. [back to top]

Transient Tachypnea of the Newborn (TTN)

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).
Due to the delayed absorption of fetal lung fluid from the pulmonary lymphatic system the increased fluid volume causes a reduction in lung compliance and increased airway resistance. Symptoms can include:

• tachypnoea >60/min
• chest recession
• nasal flaring
• expiratory grunt
• cyanosis to varying degrees.

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.
Adam was macrosomic, which coupled to his malposition, contributed to the prolonged second stage of labour. This in turn led to mild asphyxia, causing reduced pulmonary compliance and increased airway resistance. This combination of predisposing factors served to delay the absorption of lung fluid, which lead to the development of TTN. [back to top]

Care at birth

Once delivered, Adam was placed directly on his mother’s chest for a period of SSC. This quickly calmed the traumatised infant.
Although it may take hours or days for conditions associated with failure of the cardiac and respiratory systems to develop, the midwife will routinely carry out a full examination of every infant soon after birth (UKCC 1998) to detect abnormalities. In recent years there has been much debate over the timing and responsibility for this test. Should midwives, junior paediatricians, general practitioners or advanced neonatal nurse practitioners take on this role? (Bloomfield, Townsend & Rogers 2003). A recent study concluded that advanced neonatal nurse practitioners (ANNPs) were significantly more effective in detecting abnormalities than paediatric senior house officers (Lee, Skelton & Skene, 2001).
Adam was examined by an experienced midwife following delivery and except for a slightly raised temperature and an abdominal birthmark, no other abnormalities were found. [back to top]

Thermoregulation

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.
Following his traumatic delivery Adam was dried quickly and covered with warm towels during SSC with his mother. In doing so, hypothermia was avoided and his energy requirements were kept to a minimum during the post delivery period. [back to top]

Infection control

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).
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Nutrition

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]

Psychological stability

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.
In Adams case, the risk of transferring him to the neonatal unit, requiring separation from his mother was, at the time, not warranted. Close observation of the neonate could continue alongside SSC with his mother and a decision to transfer later was an option. This was possible due to the close proximity of the neonatal unit and is a luxury not available to all women. In developing countries paediatric units may be many miles away and transporting a sick infant is a complex dilemma, even in the developed world. Nevertheless simple but effective treatments can be administered resulting in high levels of success and even reduced mortality rates (Bang et al 1999). More research into the benefits of low-tech, non-invasive treatments are needed and could prove invaluable as well as being cost-effective.
Adam, although mildly distressed, remained in his mother’s arms, receiving SSC and was soothed by the sound of her voice. Breastfeeding on demand, allowed his condition to stabilise, within a stress free environment, while adaptation to the extra uterine world continued. [back to top]

Skin-to-Skin Contact (SSC)

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 is the evolutionary norm, over the past century in industrialised society, it has sadly become increasingly common to separate mother and baby. Thankfully times are changing and the importance of early bonding, with its beneficial effects, can no longer be ignored. A recent Cochrane review of SSC found many positive outcomes that include successful breastfeeding, reduced infections and complications for the pre-term infant, better bonding/attachment, thermoregulation and blood sugar stability. A happier mother and more contented infant were also noted (Anderson 2004). [back to top]

Variations on SSC

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.
Another interesting study looked at the benefits of Kangaroo care (SSC for the tiny baby) for adoptive parents and their critically ill infant. So often the father feels left out, at this vulnerable time, and to be able to bond with his newborn can prove pivotal to the experience of parenthood. The results were overwhelmingly positive and have implications for future care providers (Parker & Anderson 2002).
Another variation of SSC that has been studied is called TAC-TIC therapy. This is used for premature infants and stands for: Touching and Caressing (TAC) – Tender in Caring (TIC). It consists of gentle and light systematic SSC that is cephalocaudal (stroking from head to toe) in nature. The four main principles include gentleness, rhythm, equilibrium and continuity. By using mere delicate, stroking movements, whilst always having one hand in contact with the body, the baby will feel more secure and this will lead to positive results that include increased weight gain, secretory immunity, positive comfort behaviours and stability of physiological responses. Reduced length of hospital stay was also recorded. (Hayes 1998).
achieved as a result of constant SSC, played an important role in the resumption of normal respiration and heart rate. [back to top]

Conclusion

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.
For low-risk infants, like Adam, a more integrated approach is desirable, within a holistic framework. This reflects the trend towards non-invasive treatments, whilst at the same time not compromising safety. The UKCC (1998 p27) says: “The needs of the mother and baby must be the primary focus of your practice. The mother should be enabled to make decisions about her care based on her own needs, having discussed matters fully with you and with any other professionals involved in her care”.
Parents only want what is best for their baby and they are usually the best judges of this. Therapeutic touch in the form of SSC, TAC-TIC or Kangaroo care are all non-invasive therapies that can easily be integrated into current practice, whether in the maternity unit, NNU or at home. By involving parents in this care, they feel part of the ‘team’ and this in turn strengthens the bond with their baby, leading to the many positive benefits already mentioned.
By making SSC standard in all delivery rooms the success rates for initiation of breastfeeding are greatly increased. This in itself will have repercussions for public health as a whole and proves that even small changes in practice can have far reaching effects. [back to top]

Key points

1. SSC leads to physiological stability within minutes of initiation.
2. SSC at birth greatly helps the initiation of breastfeeding.
3. SSC is ideal for fostering good mother/baby relationships
4. SSC is a non-invasive therapy, which can be carried out anywhere.
5. SSC is a cost-effective treatment for low-risk infants.
6. SSC reduces the likelihood of secondary infection to the neonate.
7. SSC leads to fewer complications in the preterm infant.
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References

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World Health Organization (2001). As formulated in the conclusions and recommendations of the expert consultation (Geneva, 28-30th March 2001) that completed the systematic review of the optimal duration of exclusive breastfeeding (see document A54/Inf. Doc/4). See also resolution WHA54.2. [back to top]