Open Cot Research Articles

Earlier weaning of preterm newborns from an incubator to a cot at 1400 g: A randomized controlled clinical trial

IntroductionWeaning preterm newborns from an incubator to an open cot can induce a positive maternal attitude and decrease the burden in terms of healthcare costs. Therefore, this study aimed to evaluate the feasibility and safety of weaning cots at a body weight of 1400 g. MethodsA randomized controlled clinical trial was conducted on 61 preterm newborns admitted to the neonatal intensive care unit, of which twenty-nine newborns were recruited in the study group, and thirty-two newborns in the control group in a 1:1 ratio, using a random block of four. The study group was shifted to a cot at a weight of 1400 g, and the control group was shifted at a weight of 1600 g as per routine practice. Outcomes included weight gain, length of stay (LOS), and temperature control. ResultsThere were no significant differences between the two groups concerning corrected gestational age at transfer and recorded body temperature at any time point (p = 0.494, 0.713, and 0.133, respectively). No cases of weaning failure were observed in any of the newborns in the two groups. ConclusionThe present study indicated that preterm infants could be weaned safely from incubators to open cots at a weight as low as 1400 g. Further studies are warranted to confirm our findings in different settings. This project was funded by the Grant Management Department, King Fahad Medical City. Registration numberClinicalTrials.gov Identifier: NCT04351425.

An observational study of sound exposure in a single-room configured neonatal unit (SENSE study)

AimTo measure sound exposure in an Australian single-room configured, neonatal unit and compare findings to current sound level recommendations. MethodsSound meters were placed inside 51 internal environments (incubators or open cots), and within the surrounding environment of each occupied single room between September 15 and October 28, 2015. One-second incremental monitoring of decibels on an A-weighted scale (dBA), occurred over a minimum of 48 h. ResultsAll equivalent continuous sound pressure levels (Leq) were significantly higher than the recommended 45 dBA for both incubators and open cots. Maximum sound levels (Lmax) were significantly higher than the recommended 65 dBA, peaking at 126.7 dBA inside the incubator and 124.7 dBA inside the open cot. Incubators were observed to have a higher total percentage of time above 45 dBA than open cots for both day (99.84% vs. 75.59%) and night (98.66% vs. 59.56%). ConclusionSound levels exceeded the recommended maximum exposure levels outlined by the American Academy of Pediatrics (AAP). The long-term sequelae of adverse sensory exposure on preterm neurodevelopment remains unclear. Renewed attention on factors contributing to increased sound levels in neonatal units needs to be a clinical priority.

Transferring preterm infants into an open cot using a heated mattress at ≤ 1400 g.

The objective of this study is to evaluate the corrected age and weight that infants were transferred into an open cot using a heated mattress, in overall and within the subgroups of early (weight ≤ 1400 g) and standard transfer (weight > 1400 g). Retrospective cohort study in a tertiary neonatal unit RESULTS: One hundred and thirty-five preterm infants were analysed. The mean weight of moving into an open cot was 1370 ± 167 g at a corrected age 33 ± 1.8 weeks. Eighty-three infants (61%) were transferred early at a mean weight 1276 ± 98 g compared with 52 infants of standard transfer with a mean weight 1522 ± 141 g. Infants of the early group had higher weight gain, were discharged earlier and had shorter length of stay. Stable preterm infants can be safely moved to an open cot at < 33 weeks and weight ≤ 1400 g.

Sensory exposure of neonates in single-room environments (SENSE): an observational study of light

ObjectivesTo measure the internal and external light exposure of incubators and open cots in an Australian single-room configured neonatal unit and compare findings to current recommendations.MethodsLight meters were placed in...

What growth should we aim for in preterm neonates?

Abstract Growth is a characteristic of all mammals and implies a progression from infancy to adulthood, as well as being an indication of nutritional adequacy. Growth is therefore important as a ‘marker’ of health and disease, rather than being a functional outcome in itself. Knowing the weight of a baby is essential in the neonatal intensive care unit (NICU) because it determines a whole range of practices, including estimation of daily fluid and nutrient intake needs, and determining drug doses. Weight thresholds may indicate changes in other management, such as when the baby can be moved from an incubator to an open cot, or perhaps when the baby is ready for discharge. Parents and families perceive weight gain as clear tangible proof that their baby is getting better. Parents are delighted when they see their baby has gained weight, and are generally concerned when they do not. The use of growth charts to plot growth with lines indicating apparent ‘normal’ growth trajectories may suggest to parents (and perhaps staff) that we know what is best. However, the optimal speed of weight gain, or growth, remains a matter of uncertainty: rapid growth may be harmful, slow growth might sometimes be acceptable. Growth must be seen in the context of optimising nutritional status, rather than simply achieving increases in auxological parameters. In this review we describe the science underpinning current thinking in nutritional management of babies on the neonatal care unit, give guidance for optimal nutrition and outline the short, medium and long term consequences of early nutritional care.

Evidence-based thermal care of low birthweight neonates. Part one

Neonates are at a high risk of temperature loss. Those born at less than 30 weeks' gestation should be placed in a plastic bag or wrapped immediately at birth, drying the head and putting on a hat, while maintaining routine precautions, such as warming the delivery room, pre-warming surfaces and eliminating draughts. Environmental humidity greater than 50 per cent is required, with up to 85 per cent for extreme prematurity, subject to individual assessment. Using regular or, ideally, continuous monitoring, the child's central (core) body temperature should be maintained at 36.7-37.3 degrees C with a core-peripheral difference, if measured, of 0.5-1 degrees C. Stabilised newborns can be transferred from an incubator into an unheated bassinet or open cot at an optimum weight of > 1.6kg, however individual assessment of each neonate is essential before transferring out of the incubator. In the absence of sufficient research, fully evidence-based recommendations cannot be made and individual unit protocols should be followed with careful clinical judgement. In resource-limited settings--in developing countries around the globe, for example--staff should be trained in simple resuscitation techniques, with keeping newborns warm as a key objective.

Transfer of preterm infants from incubator to open cot at lower versus higher body weight

A key criterion for discharging preterm infants home from nurseries is their ability to maintain temperature once transferred from incubators to open cots. The timing of transfer is important given the preterm infant's immature thermoregulatory mechanisms. To determine the effects of body weight in transferring preterm infants from incubators to unheated open cots. Electronic databases, the Cochrane Central Register of Controlled Trials, clinical trials registers and the abstracts of the Society for Pediatric Research were searched. Randomised and quasi-randomised controlled trials comparing transfer of preterm infants from incubators to unheated open cots at lower and higher body weights. Data collection and analysis was performed in accordance with the methods of the Cochrane Neonatal Review Group. Four eligible studies were identified. Two of the identified trials were assessed as having good methodological quality. Two studies reported daily weight gain (calculated as growth velocity); the lower body weight group had a significantly greater daily weight gain [pooled mean difference (MD) 2.66 (95% confidence interval (CI)1.37 to 3.95). One study reported a larger proportion of infants transferred at the higher body weight had an episode of low temperature in the first 72 hours; while no difference between the two groups was found in the proportion of infants experiencing cold stress post-transfer to discharge. Two studies report no difference between the two groups in requiring an overhead heater for temperature maintenance [pooled RR 1.43 (95% CI 0.35 to 1.18). No statistically significant difference was shown for proportion of infants returning to an incubator [three studies (N = 336) [pooled RR 1.78 (95% CI 0.77 to 4.08].Two studies report there was no statistically significant difference in time spent in an open cot post transfer to discharge; while one study found infants transferred at lower weights had a significantly reduced length of stay [MD -9.00 (95% CI -13.29 to -4.71), a second study found no differences between the two groups [MD 0.30 (95% CI -5.11 to 5.71). In these two studies not breastfeeding at discharge was not significantly different between the lower and higher body weight groups [pooled RR 1.02 (95% CI 0.69 to 1.51). Medically stable preterm infants can be transferred to unheated open cots at a lower body weight of 1600 grams without adverse effects on temperature stability or weight gain. Earlier transfer does not necessarily result in earlier discharge.

Transferring preterm infants from incubators to open cots at 1600 g: a multicentre randomised controlled trial

ObjectivesTo determine the effects on weight gain and temperature control of transferring preterm infants from incubators to open cots at a weight of 1600 g versus a weight of 1800...

Practice variation in the transfer of premature infants from incubators to open cots in Australian and New Zealand neonatal nurseries: Results of an electronic survey

The incubator environment is essential for optimal physiological functioning and development of the premature infant but the infant is ultimately required to make a successful transfer from incubator to open cot in order to be discharged from hospital. Criteria for transfer lack a systematic approach because no clear, specific guideline predominates in clinical practice. Practice variation exists between continents, regions and nurseries in the same countries, but there is no recent review of current practices utilised for transferring premature infants from incubators to open cots. To document current practice for transferring premature infants to open cots in neonatal nurseries. A descriptive, cross-sectional survey. Twenty-two neonatal intensive care units and fifty-six high dependency special care baby units located in public hospitals in Australia and New Zealand. A sample of 78 key clinical nursing leaders (nurse unit managers, clinical nurse consultants or clinical nurse specialists) within neonatal nurseries identified through email or telephone contact. Data were collected using a web-based survey on practice, decision-making and strategies utilised for transferring premature infants from incubators to open cots. Descriptive statistics (frequencies and crosstabs) were used to analyse data. Comparisons between groups were tested for statistical significance using Chi-squared or Fisher's exact test. Significant practice variation between countries was found for only one variable, nursing infants clothed (p=0.011). Processes and practices undertaken similarly in both countries include use of incubator air control mode, current weight criterion, thermal challenging, single-walled incubators and heated mattress systems. Practice variation was significant between neonatal intensive care units and special care baby units for weight range (p=0.005), evidence-based practice (p=0.004), historical nursery practice (p=0.029) and incubator air control mode (p=0.001). Differences in these variables were also found between nurseries in metropolitan and rural locations. Practice variation exists however; many practices are uniformly performed throughout neonatal nurseries in Australian and New Zealand. Commonality was seen between countries and in nurseries with a neonatal intensive care unit. Variation was significant between neonatal intensive care units and special care baby units and nurseries in metropolitan and rural locations.

Strategies for getting preterm infants home earlier

Neonatal intensive and special care is an expensive and limited health resource. Having a child in hospital is stressful and inconvenient for families, and may result in unbudgeted costs and...

Skin conductance as a measure of pain and stress in hospitalised infants

Background Reliable and valid methods of measuring pain responses in infants continue to be sought as a means of evaluating the effectiveness of pain reduction strategies. Skin conductance has recently been shown to be a promising physiological indicator of pain and stress in premature and term infants. Aim To evaluate changes in skin conductance in hospitalised infants under different environmental conditions and during both painful and non-painful procedures. Methods Measurements of skin conductance activity were made in infants under three different environmental temperature conditions (open cot, incubator and overhead radiant heater), during the routine non-painful nursing procedure of either nappy change or oral feeding, and whilst undergoing the painful procedure of heel lancing for blood sampling. Results Skin conductance activity in 21 infants was studied on 43 separate occasions. Skin conductance activity was highly variable between infants but did not differ significantly under the three environmental conditions. Routine nursing care did not result in a significant increase in skin conductance activity above baseline; however, on cessation of care there was a significant reduction to levels below baseline ( p < 0.05). Conversely, during the heel lance procedure, skin conductance activity significantly increased upon lance ( p < 0.05) and remained elevated following completion of the procedure. There were no statistically significant differences between skin conductance activity changes from baseline as a result of routine nursing care compared to that of the heel lance procedure. Conclusion Due to large variability in skin conductance activity further studies are needed before this technology can be recommended as a clinically useful indicator of pain and stress in neonates.

Feasibility and safety of early transfer of premature infants from incubators to cots: A pilot study

To document whether medically stable infants can be transferred safely from incubators to unheated, open cots at 1500 g. Four cohorts were recruited in a stepwise observational trial of transfer from incubators to unheated, open cots. We aimed to transfer the first 15 infants into cots on reaching a weight of 1800 g, the second at 1700 g, the third at 1600 g and the fourth at 1500 g. Nursery temperatures were set at 25 degrees C. The primary outcome measure was failure of transfer defined as the inability to maintain body temperatures in a cot despite additional coverings, with two consecutive axillary temperatures below 36.6 degrees C 1 h apart. Secondary aims were to determine temperature stability, growth, medical complications and time to discharge for these infants. Weight and corrected gestation at discharge were recorded. A total of 61 infants were recruited and transferred into cots. Cohorts were similar in gestation and sex. Infants recruited to the 1500 g cohort had higher birthweights than the other cohorts. There was no difference in the rate of infants failing transfer into cots between cohorts. Rate of weight gain before and after transfer and the number of high and low temperatures per infant after transfer was not different between cohorts. There were no differences between cohorts for discharge weight or corrected gestation. The results of this pilot study indicate the potential to transfer very low birthweight infants to an open unheated cot at a bodyweight of 1500 g. This study provides information for the design of future randomized controlled trials that are required to confirm the findings of this study before routine adoption of this intervention into clinical practice.

Transfer of preterm infants from incubator to open cot at lower versus higher body weight.

The use of incubators in helping to maintain a thermoneutral environment for preterm infants has become routine practice in neonatal nurseries. As one of the key criteria for discharging preterm infants from nurseries is their ability to maintain temperature, the infant will need to make the transition from incubator to open cot at some time before discharge. The timing of this transition is important because when an infant is challenged by cold, the infant attempts to increase its heat production to maintain body temperature. The increase in energy expenditure may affect weight gain. The practice of transferring infants from incubators to open cots usually occurs once a weight of around 1700-1800 g has been reached; however, this practice varies widely between neonatal units. This preferred weight mark appears to be largely based on tradition or the personal experience of clinicians, with little consideration of the infant's weight or gestational age at birth. The main objective was to assess the effects on weight gain and temperature control of a policy of transferring preterm infants from incubator to open cot at lower versus higher body weight. Searches were undertaken of MEDLINE from June 2003 back to 1966, CINAHL from June 2003 back to 1987 and the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2003). The title and abstract of each retrieved study were examined to assess eligibility. If there was uncertainty, the full paper was examined. Trials in which preterm infants were randomly allocated to a policy of transfer from incubators to open cots at a lower body weight versus at a higher body weight. Quality assessments and data extraction for included trials were conducted independently by the reviewers. Data for individual trial results were analysed using relative risk (RR) and mean difference (MD). Results are presented with 95% confidence intervals (CI). Due to insufficient data, meta-analysis could not be undertaken. Four studies were identified as potentially eligible for inclusion in this review. Two studies were excluded as random allocation to the exposure was not employed. One study is pending, awaiting additional information from the authors. Therefore, one study involving 60 preterm infants, employing a matched-pairs design, which compared the transfer of infants to open cots at 1700 g versus 1800 g, is included in this review. Only two outcomes could be included from this study; return to incubator and daily weight gain. No statistically significant difference was shown for either return to incubator (RR 2.00, 95% CI 0.40 to 10.11) or daily weight gain [MD 4.00 g/day (95% CI -5.23, 13.23)]. Due to small numbers, effects on clinically important outcomes could not be adequately assessed. There is currently little evidence from randomised trials to inform practice on the preferred weight for transferring preterm infants from incubators to open cots. There is a need for larger randomised controlled trials to address this deficiency.

CO2 rebreathing: a possible contributory factor to some cases of sudden infant death?

Physical and geometrical conditions influencing carbon dioxide (CO2) accumulation near the face of a sleeping infant positioned deep in a cot or pram (open cot shaft) or underneath bedding (closed cot shaft) were investigated. By means of mathematical and data-based simulation, and an experimental rebreathing model, both hypothetical (dry, exhaled air +20 degrees C) and more physiological conditions (heated, humidified exhaled air, room temperature +20 degrees C; with and without pooling of cold air within the shaft) were tested. With exhaled air at +20 degrees C, the CO2 concentration increased to about 10% within 5 min. The increase was faster the smaller the volume, and the smaller the opening of the cot shaft. When expiratory air was heated, the CO2 concentration increased with the same speed as when the shaft was closed, but to only 0.1-0.3% when the shaft was open. Pooling of cold air in the shaft increased CO2 accumulation 70-200 times the concentration in air (to <5.5%) when the shaft was open. Turbulence of the air outside the open shaft reduced the increase in CO2 concentration. The experiments imply that CO2 may accumulate around an infant's head when placed deep in a cot or pram with the bedding and walls creating a narrow, vertical, shaft-like tunnel to the surrounding air. Although the CO2 concentration may theoretically attain dangerous levels in such circumstances, a rapid equilibrium between the air within and outside the cot usually occurs due to convection of the expiratory air and turbulence from drafts, the infant's body movements and breathing. Such factors will largely eliminated any significant rebreathing with the exception of the extreme situation when expired air is contained within a closed space.

Effect of phototherapy on thermal environment of the newborn.

Oxygen consumption was studied in 40 newborn babies undergoing phototherapy for hyperbilirubinaemia, both when enclosed within an incubator or nursed in an open cot. Exposure to phototherapy caused a rise in temperature at the mattress surface. This could result in overheating a baby nursed in an incubator, but by contrast is likely only partially to compensate for the loss of insulation of an unclothed baby in an open cot.