Cobedding IN NICU - Grade: A PDF

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Research paper about the effectiveness of cobedding in NICU...

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Running Head: CO-BEDDING PREMATURE MULTIPLES: AN INCREASE IN STABILITY 1

Co-bedding Premature Multiples: An Increase in Stability Samantha Still San Francisco State University

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Background In America alone, 450,000 infants per year are born prematurely. From that, 60% of all twins and 90% of triplets are born before 37 weeks gestation (Chauhan, 2010, p. 307). Infants born before the normal 40 weeks are prone to a host of issues; ranging from jaundice to complete organ failure as well as death. So that leaves one question: how can we prevent infants from suffering the complications that come in tandem with preterm birth? Premature multiples or any infant born between 26 weeks, coined “micro-preemies,” or preterm infants born between 26 and 37 weeks gestation are prone to a host of health issues, the issues becoming more prominent and pervasive the farther from a full term pregnancy the infant is born. More pervasively, multiple-infant births are more likely to be born prematurely, meaning that multiples are more prone to the myriad of health problems associated with premature birth. The most common issues found in preterm births tend to be respiratory issues such as apnea or bronchopulmonary dysplasia, cardiovascular issues, and gastrointestinal issues (York, 2002, p. 95). These problems must be corrected with a variety of measures, ranging from nasogastric tubes to constant bloodwork and monitoring. The constant monitoring and hospital environment is not an easy transition from womb to world, and as a result, most preterm infants deal with a great amount of discomfort, struggle to gain weight, and to be able to maintain their own bodily functions such as breathing, swallowing, and digestion. Co-bedding is the practice of placing two or more multiple birth infants in the same incubator or crib. Co-bedding originally came into practice as a way to soothe newborn twins or multiples as it was theorized that placing multiples together rather than apart mimicked the settings of the womb in which they were accustomed to, this mimicking of the intrauterine

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environment easing the transition into the world. Despite there being no solid pathophysiological evidence that backs the proposed benefits co-bedding, it is becoming increasingly more common practice in the United States. Regardless of its popularity, many experts raise concern about it’s practice, citing complications with sleep cycles, and increased risk of sudden infant death syndrome (SIDS), as well as infection being passed more easily between the multiples being co-bedded (Di Nonno Chin, 2006). While more research needs to be conducted, co-bedding has been associated with a calming effects on pain responses (Badiee, 2014, p. 267), and an increase in mean weight gain (Di Nonno Chin, 2006). However, weight gain seemed to be the only predominant marker of improvement as in Di Nonno Chin’s study, while co-bedded twins showed significant weight gain, they did not show any fewer signs of apnea, bradycardia, or desaturation. In preterm infants, weight gain is the identifying marker of improvement in overall health; improvement in weight gain is directly correlated to shorter hospital stays and fewer complications (York, 2002, p. 295). Does co-bedding have a significant effect on positive outcomes of infants? Because it is becoming more common practice, it is important to determine the efficacy of this rapidly-expanding method of care, regardless of the pathological reasons. What is the effect of co-bedding in improving overall stability in premature multiples  born on or before 32 weeks gestation in the first 72 hours of life? What will be examined is premature multiples, specifically born before or on 32 weeks gestation. Thirty two weeks gestation was chosen as infants born on or before this date are more susceptible to a variety of different health issues, and are more likely to have a weight deficit which needs to be gained, improvement in overall

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stability and weight gain are more prominent. The intervention is the idea of co-bedding multiples, keeping the infants in the same incubator or crib for the duration of their hospital stay. This is in comparison to the normal standard practice, in which multiples tend to be kept in individual incubators away from each other. The theorized outcome is that the practice of co-bedding will allow for more positive outcomes; specifically, decreased pain responses, faster weight gain, and a faster gained ability and self-monitoring of bodily functions.

Search Strategies and Critical Appraisals While conducting research on this topic, two journals were found that best encompassed the population and issue at hand. Whilst organizing the search, PubMed was utilized, focusing on the key terms “Co-bedding,” “Premature births,” and “NICU.” These search terms yielded 24 articles, two of which will be critiqued in full. Critical Appraisal #1: Effect of cobedding twins on coregulation, infant state, and twin safety. The first paper evaluated the significance of cobedding in terms of safety of twins as well as coregulation of the infants. The problem and the intent of the research was clearly described in both the abstract and in the methods section of the article: to determine the efficacy of cobedding on twins in terms of safety and coregulation in a neonatal intensive care unit. The conceptual framework of the article focused on the environment of the patients, catering their nursing care to providing the proper environment for the patients to flourish. While not explicitly stated in the journal, the conceptual framework was a biomedical model continually interwoven throughout the article.

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The articles cited in the review of literature section are all relevant to the topic; the researchers focused on presenting information that was significant, stating, “Synchronization or coregulation is the way newborn twins support each other in the physiologic transition to postnatal life and in the achievement of stable sleep/awake states through activities mediated by physical contact, (Hayward, 2015, p. 195)” emphasizing the importance of physical contact between twins and higher order multiples, a statement which reiterates their hypothesis regarding the importance of cobedding. In the methodology section, the design of the study was very meticulously explained; the primary and secondary objectives were explicitly stated, as well as the methods of data collection which in turn supported the objectives. It was stated that several physiological variables such as sleep cycles, heart rate, oxygen saturation, and temperature were monitored as a way to quantify what the researchers defined as “stability;” these markers served as a way to monitor the wellbeing of the subjects. Adverse events were also clearly defined as heart rate drops, apnea, fever, and decreased oxygen saturation. By clearly defining what were considered markers for stability and adverse events, it allowed the data to be easily interpreted. It was also explained that the test subjects being studied in the NICU were compared with infants who received traditional NICU care, in individual incubators. The results section explained that over 5 years, 117 sets of twins were monitored, but, their overall outcomes did not differ significantly from premature infants who received standard care. While results in overall stability (measured by physiological factors) did not differ significantly, it was noted that twins that were co-bedded had different sleep cycles than those who did not, spending greater amounts of time in quiet, deeper sleep. These results leave the

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question: while not having significant effects on physiological factors, is it worth it to co-bed premature multiples based on the fact that it seems to provide more psychosocial and emotional comfort? The data in the results section is clarified by figures and broken up into different areas of results; separating the physiological results of the study from the behavioral results, comparing the results from the standard practice group to those who were co-bedded. The discussion section compared the results of their study with the research discussed in the review of literature section, stating, “We found that over time (7 days), there was a greater increase in the amount of time co-bedded twins spent in the same states when compared to non-cobedding twins.” This supported the data in the review of literature section which affirmed that physical touch between twins and multiples helped in coregulation.The researchers reaffirmed that their research aligned with the current belief that long periods of cobedding led to increased physiological stability, but also stated, “To our knowledge, this is the first clinical trial to examine the effect of cobedding on twin coregulation and safety,” leaving the implication open for further education and research on the topic. In general, the title and abstract of the study accurately reflect the article: focusing on the results and objectives of the study: the efficacy of co-bedding twins on stability and regulation. However, the references and literature used in the study is dated, some of the articles dating back to the late 1980s and early 1990s, decades before this study was actually performed. Critical Appraisal #2: Cobedding of twin premature infants: calming effects on pain response. The objectives of this study were made very transparent: does co-bedding have an effect on pain response in premature twin infants? By using pain response as an indicator for the

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efficacy of co-bedding, with the comparator of standard practice of individual incubation of infants, the study was easy to interpret. Similarly to the last article critiqued, the conceptual framework appears to be in align with primarily improving the psychosocial and emotional wellbeing of patients rather than the physiological outcomes by improvement of their environment. The biggest flaw of this study was a deficit in a review of literature section. The review of literature section allows comparisons of the results of the study to pre-existing research and allows the reader to evaluate the significance of the study. The lack of a review of literature section made this sort of comparator impossible without doing additional outside research on the topic, a detriment to the study as a whole. The method section clearly outlines the process used for data collection: newborns of gestational ages 26-34 weeks who were under 20 days of postnatal age were included in the study: when heel lancing was required to take blood glucose levels, their pain response was evaluated and compared to those who received standard practice of care. Oxygen saturation and heart rate were recorded during the heel lancing procedure and pain was assessed using the PIPP scale. This description and the tests used were appropriate for the study; using pain response as a variable allows a researcher to assess the levels of comfort that co-bedding provides. The results section showed that in terms of pain response, co-bedding was significant in terms of comfort to infants. Infants who were co-bedded did not have as much of an increase in heart rate after the heel lancing procedure, and their pain response was less than those who were in standard care, seen when stated, “Severe  pain, characterized by a PIPP score of more than 12,

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was seen in 20% of newborns in the standard care group and 6% in the cobedding group. Eighteen percent of newborns in the cobedding group and 2% of patients in the standard care group did not feel pain…” It was also noted that infants co-bedded cried for a shorter amount of time after the heel lance procedure than those who were not. However, because the population of the study is unable to verbally express their level of discomfort, pain is a very subjective indicator, and because researchers themselves were the ones conducting the pain evaluations on the infants, their bias in wanting the study to succeed could have influenced the outcomes of these pain assessments. Limitations or potential bias of the researchers was not at all indicated in the study. Because this study lacks a review of literature section, the results of this study are not compared to any other findings, making it hard to indicate whether or not the results of this trial are truly statistically significant. However, the study does state, “Development  of new nonpharmacological pain control methods is very important for the management of pain and stress in preterm infants who are admitted to NICUs,” discussing the implications for further research and practice on the topic. The tables and figures in the discussion and method section quantify the data in a way that makes it easier to understand, but seem also inconsequential as there is nothing to compare the data to because of the lack of a review of literature section. The title and abstract accurately represent the contents of the article, explicitly stating the objectives of the study, but similarly to the last study, the references remained outdated, potentially because of the minimal amount of research done on this topic.

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Overall Findings In general, it was shown in the two studies that co-bedding did not have a significant impact on improving the physiological state of an infant, but rather, improved the emotional and psychosocial wellbeing of the subject. Both studies showed not a significant improvement in physical health, but instead improved sleep and behavioral regulation, as well as a limited pain response in comparison to the standard care, individual incubator counterparts.

Theoretical Framework: Kolcaba’s Theory of Comfort Katharine Kolcaba was a nurse and a nurse theorist who coined the idea of “comfort” and its’ applications in nursing. To put it simply, to Kolcaba, the ideal outcome of complete holistic nursing care is comfort. The aim of the Comfort Theory was to place comfort at the forefront of nursing care and nursing goals; that nurses and all healthcare professionals should prioritize the idea of “holistic comfort” as the main objective of their care. The theory of comfort places the outcome of the patient before the medicine, and focuses on individualizing nursing care for each patient to achieve what they deem to be “holistic comfort.” Kolcaba theorized that there are three forms of existing comfort: relief, ease, and transcendence, and then four contexts in which comfort occurs: physical, psychospiritual, environmental, and sociocultural (Kolcaba, 2003, p. 15). When discussing the three forms of comfort, relief can be described as having a specific need met, and nothing more. For example, if a person is thirsty and is provided with a glass of water, they experience relief from thirst. The second form of comfort is ease, described as the state of calm or contentment. Finally, the third

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form of comfort is coined as “transcendence,” defined as “the state in which one could rise above problems or pain.” Kolcaba goes on to describe the four contexts in which comfort exists: first, physical comfort pertains to a person’s physical and bodily needs, their state of health, or their homeostatic mechanisms. The second context of comfort is psychospiritual, which relates to a person’s awareness and understanding of themselves and the ways in which their identities intersect. The environmental comfort relates to the external background of a person’s experience; the environment in which they receive comfort. Finally, the sociocultural context of comfort pertains to one’s place in society and personal relationships with friends and family. Kolcaba goes on to explain that all contexts and forms of comfort intersect and continuously interact with each other: a person’s in a state of ease can receive the context of this comfort in all four states simultaneously. This “holistic comfort” Kolcaba coined meaning that a person’s needs are being met in all forms and contexts of comfort. Additionally, a nurse can seek to simultaneously provide all three forms of comfort in any context; as Kolcaba states, a holistic form of comfort is the most essential outcome of healthcare (See Appendix D). Assumptions of the Comfort Theory In evaluating the ways that the Comfort Theory intersects with the PICO question at hand, several assumptions must be made. First, we have to understand that the idea of comfort is a complex and nuanced topic. While the idea of comfort can be applied to the population, premature twins or higher order multiples, in this case, because of the age of the patients, the idea of comfort is just as applicable to the families. Additionally, we have to understand that both families and infants have holistic and nuanced responses to complex stimuli such as the

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hospital setting. An important assumption is that the nurse or healthcare provider employing the comfort theory understands that while patients and families aim to have their needs for comfort met, it is a constant process that sometimes must employ the aide of others; additionally, that each individual varies in what their definition of comfort is The comfort theory also assumes that comfort is the desired outcome of everyone involved: patients, family, and healthcare providers; more specifically, that the holistic outcome of comfort is integral to nursing as a whole, and the axis on which pediatric nursing turns (Kolcaba, 2006, p 193). The most integral assumption of the comfort theory is the comfort is always attainable. This assumption is most applicable to this specific study as measuring comfort in a neonatal population is subjective, as the population cannot voice their desires or needs. More pressing, it may have the appearance that the needs of a neonate population are not complex, and do not extend beyond the need for immediate satisfaction of physical comfort and relief. However, their response to cobedding shows a capacity for a higher understanding of comfort. Strengths and Limitations of the Comfort Theory The strongest and most compelling point of the Comfort Theory is that it places the idea of “patient first” at the forefront of its analysis. More importantly, it forces healthcare providers to think critically and evaluate all aspects of a patient’s life: both their physical and emotional needs, as well as integrate their relationships with others into their plan for care. This type of critical thinking and individualized care leads to better patient satisfaction as well as better health outcomes.

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However, the fast-paced environment of the hospital isn’t always conducive for the application of the comfort theory. In reality, many nurses have a high number of patients that could limit the amount of time committed to applying this theory in practice. When a nurse is struggling balancing five high acuity patients, meeting their needs of comfort beyond physical could potentially move down on one’s list of priorities, a factor that Kolcaba failed to consider. Another limitation that has not been considered is the subjectiveness of the term “comfort” and the way healthcare providers interpret it. Being able to provide “comfort,” which has no settled definition, in a holistic matter in the way that Kolcaba has proposed requires a great deal of critical thinking and consideration into a patient’s lif...