Tracing the threads: a system dynamics and network diffusion modelof kangaroo care implementation in neonatal care.

Skin-to-skin contact (SSC) consists of positioning the diaper-clad infant against the parent's chest and is considered a nursing practice rooted in family-centered care (FCC).1 SSC implies simultaneous parental presence and helps to facilitate their involvement from the earliest hours of their preterm infants' lives as this intervention is delivered by parents.1 FCC has gained worldwide popularity in recent years to promote parental presence and active participation of parents in care during neonatal intensive care units (NICUs) hospitalization.2 Both practices relate to developmental care (DC), which regroups specific interventions aimed at reducing stress and improving infant neurological development.3 It is well recognized that promoting SSC and FCC are recommended in the NICU, given its many health benefits for preterm infants and parents. SSC has been found to favor maternal attachment, enhance paternal role achievement and interactive behavior, reduce maternal and paternal anxiety, and promote infants' long-term cognitive development.4, 5 On the other hand, FCC can improve the clinical outcomes of preterm infants such as greater weight gain, as well as the psychological well-being of the parents.6 More specifically, parental involvement in NICU care is associated with reduced infants' length of hospital stay and collaboration with professionals increased parental satisfaction.7 Daily maternal presence during NICU hospitalization is associated with a decrease in emotional and behavioral problems in school-age children.8 Noteworthy, parental presence during NICU hospitalization with more frequent holding of their infant in their arms, is associated with better infants' neurobehavioral development, such as better quality of movements and reduced arousal, at term equivalent age.9 Given their benefits and driven by the DC philosophy, nurses should encourage SSC as well as FCC to provide parents with opportunities for collaboration and care involvement in the NICU. Yet, significant barriers may impede nurses from implementing SSC and FCC in the NICU, namely the lack of adequate training for nurses about SSC.10 As optimal implementation of FCC and SSC may depend on the nurses' perceptions of these DC practices, along with the training and education about these practices provided in the NICU, the aim of this manuscript is to explore the association between NICU nurses' perceptions about SSC and FCC and their unit's ability to provide FCC and SSC. Secondary analysis was performed from a larger comparative international study that was conducted between October 2017 and July 2018, where 202 NICU nurses completed paper or online questionnaires on their perceptions about their unit provision of FCC and SSC.11 Prior to the beginning of the study, ethical approval was obtained in both Canada (MP-21-2018-1854) and France (20181306005 and CNIL 2211490 v0). Nurses were recruited from four level III university-affiliated NICUs (intensive and intermediate care) in Canada and France admitting infants born between 23 and 40 weeks of gestational age. Total number of beds ranged from 30 to 65 in Canada and from 26 to 54 in France. The number of nurses working in the NICUs in France varied from 60 to 100 and in Canada from 113 to 190. Nurses' mean age was 33.9 ± 9.1 years, and they had a mean of 8.1 ± 7.0 years of neonatal care experience, and a mean of 7.1 ± 6.9 years on the sampled unit. Most were women (97.5%, 197/202) and almost half of the sample worked during the day (49.7%, 94/189) followed by the night (27.0%, 51/189), the evening (7.9%, 15/189), and rotation across the three shifts (15.30%, 29/189). Eighty-five nurses (42.1%, 85/202) in our sample had completed a bachelor's degree. The SSC questionnaire evaluated NICU nurses' attitudes and knowledge about SSC as well as their perception of their unit's SSC training and education in addition to implementation.12 It contained 20 items with a five-point Likert scale ranging from 1 "never" to 5 "always". It is separated into four subscales: knowledge (five items), personal attitudes and beliefs (four items), staff training and education (five items), as well as the unit-level implementation of SSC (six items). Training and education, and implementation refer to several aspects of the practice of SSC, including the availability of guidelines for its practice, proper training of health care professionals in SSC, interdisciplinary collaboration in supporting SSC, and adequate implementation on the unit.12 Higher scores reflect more favorable perceptions. The FCC questionnaire inquires as to the nurses' perceptions of whether the unit staff respects families, collaborates with them, and provides support.13 It included 20 items with a four-point Likert scale ranging from 1 "never" to 4 "always" divided among three subscales: respect (six items), collaboration (nine items), and support (five items). Scores of the subscales could vary from 6 to 24 (respect), 9 to 36 (collaboration), and 5 to 20 (support) while the total score could range from 20 to 80. Higher scores on each subscale in addition to the total score indicate more favorable perceptions that their unit is providing these aspects of FCC. Both questionnaires had adequate validity and reliability in French and English versions.12-14 Descriptive analyses (mean, standard deviation) were calculated for the subscales of each questionnaire as well as for the FCC questionnaire total score. Associations between subscale and total scale scores of FCC and SSC questionnaires were explored using Pearson's correlations. Descriptive analyses were also computed to describe the demographic data of the sample. Statistical analysis was done using SPSS v.26 with an alpha of 0.05. The nurses' mean scores for all subscales and total scores of the SSC and FCC questionnaires were shown in Table 1 and the correlations among these scores were shown in Table 2. Nurses' total FCC score (64.79/80), in addition to their SSC attitude subscale score (18.24/20) and knowledge subscale score (21.53/25) were high (Table 1). Results show that the nurses' FCC total score was significantly correlated with all SSC subscales scores, ranging from weak (0.17) to moderate (0.30) correlations (Table 2). Our findings indicated that the nurses' favorable perceptions that their unit is providing FCC are minimally associated with greater SSC personal knowledge (0.17) and attitudes (0.19), as well as with their better perceptions of their unit performance in terms of training and education (0.24) along with SSC implementation (0.30). Among all subscales of both practices, the highest correlations were found between the nurses' perceptions of their NICU providing support to families (FCC support subscale score) and SSC available training and education (0.29) as well as between the FCC support subscale score and SSC implementation on their unit (0.31). In addition, a similar association (0.30) was found between the nurses' perceptions of their unit's implementation of SSC and the total score of care being family-centered in their NICU. This secondary analysis offers an exploration of how nurses' perceptions about their NICU's ability to provide FCC are associated with SSC and brings new knowledge to guide neonatal practice. Overall nurses considered that their unit performed well with respect to FCC and their knowledge and attitudes about SSC were favorable. It is interesting to note the associations between the nurses' perceptions that their NICU provides support to parents and the staff training and education as well as implementation of SSC in the NICU. These findings might be interpreted to indicate that when SSC training and education are available and provided to nurses in addition to being well implemented in their neonatal unit, nurses have more favorable perceptions that their NICU supports FCC and vice versa. Enhancement of DC practices not only requires positive nurses' perceptions but also high professional competency in addition to favorable organizational structures which can be maintained through educational nursing training on DC as well as proper management support.15 A recent study showed that a virtual education program can improve NICU nurses' DC perceptions and knowledge.16 Accordingly, fostering the implementation of these practices in NICU settings could be accomplished through implementation science research related to either FCC or SSC. Nurses embracing favorable perceptions regarding their unit performance of FCC and SSC might translate into positive health outcomes for preterm infants and their parents. Interventions during NICU hospitalization such as SSC should be implemented in addition to other DC practices as these interventions encourage parents' presence and involvement in the care of their infant.17 As our study nurses worked mostly on the day shift, our findings may be explained by possibly greater parental presence and care involvement during the day where parents may request these practices, which in return may facilitate FCC and support nurses' favorable attitudes towards SSC. The nurses' knowledge and favorable attitudes concerning SSC may also be accounted for by their educational level as a higher degree of education has been associated with more SSC knowledge and favorable attitudes18 and close to 45% of our sample of nurses had completed a bachelor's nursing degree. As one component of FFC, SSC is credited as one of the most powerful interventions that is performed by parents with benefits for both parents and preterm infants.1 Although SSC and FCC could be considered as separate practices in DC, this secondary analysis shows that NICUs promoting one of those practices appear to also support the other. Hence, nurses who perceive that their unit performs well in providing FCC to parents also perceive their unit implements SSC and provides training and education about SSC. Highlighting this relationship is essential from theoretical and practical perspectives to better understand DC as a concept with integrated rather than independent components. This view of DC philosophy could guide neonatal clinical practices and encourage nurses to promote one intervention by supporting the other. As such, nurses who would aim to help parents achieve SSC in NICU are also supporting FCC, and therefore expose infants and parents to the combined known benefits of both practices. Noteworthy, an intervention about teaching staff how to work collaboratively with parents was found to increase parental presence in the NICU and SSC19 in addition to the quality of FCC according to both parents' and nurses' perceptions.20 Accordingly, focusing on training nurses to be able to work in collaboration with parents to provide care and enhance the implementation of DC practices. Future research should also consider investigating the relationship between any of these DC practices to build on evidence to support this unified view of DC interventions. The ethical approval was obtained in both Canada (MP-21-2018-1854) and in France (20181306005) and CNIL 2211490 v0). Thank you the Réseau de recherche en interventions infirmières du Québec/Quebec Network on Nursing Intervention Research [RRISIQ] for funding. The authors declare no conflict of interest.

To explore factors that impact nurses' knowledge, perceptions and practice related to kangaroo care in neonatal intensive care units in China. It is recognised extensively that kangaroo care is an effective intervention for improving the outcomes of preterm infants and has been recommended as a routine practice for neonatal care. However, this practice is uncommon in China and little is known about neonatal nurses' knowledge and attitude. A descriptive cross-sectional survey. An online questionnaire was completed by 830 neonatal nurses. Data were analysed using measures of central tendency, dispersion, ANOVA, t tests and the general linear model. A total of 48.2% of the participants reported practicing kangaroo care. Range of score for each scale was knowledge 0-16 (M=9.62), perceptions 28-103 (M=79.99), barriers 17-85 (M=65.40) and practice 11-55 (M=34.44). Experience in using kangaroo care was a primary factor for the scores of four scales. Particularly, experienced nurses had higher level of knowledge and perceived less barriers. Respondents' role in neonatal intensive care units considerably influenced perceptions and practice level. Nurses' highest education and neonatal intensive care unit level also influenced the knowledge and practice score, separately. A major barrier to practice was the reluctance of physicians, nurses and parents. Neonatal nurses' knowledge, attitude and practice levels related to kangaroo care were relatively low. Results suggested that leadership and knowledgeable practitioners could initiate education and clinical training to improve nurses' knowledge and awareness on the efficacy of kangaroo care. Moreover, initiatives and behaviours would be enhanced following increased knowledge and perceived value. Such barriers as the reluctance of medical staff may likewise be lowered or removed after experiencing kangaroo care. Neonatal nurses' knowledge and belief need to be improved for optimal practice of kangaroo care. Organisational support and clear guidelines are also in need for successful kangaroo care.

<p>Human infants share common biological and developmental needs in the postnatal period that are optimally met during intimate contact with their mother or primary caregiver. In the case of infants hospitalised in tertiary-level neonatal intensive care units (NICUs), there is a departure from instinctual caregiving and nurturing found in the mother-infant pair, due in part, to a model of care which supports maternal-infant separation. This can lead to suboptimal physiological responses, altered neurobiology and life-long negative health effects. The social construction of neonatal care currently positions it within the paradigm of biomedical science. Where family-centred, developmental care frameworks have been integrated, and Kangaroo Mother Care (KMC) has been embedded into caregiving routines, enhanced patient, whānau/family, staff and organisational outcomes have been found. This study is underpinned by the importance of KMC for the enhancement of infant and whānau/families’ health and developmental outcomes. Despite its classification as an evidence-based practice, and recommendations by the World Health Organisation for its use in all healthcare settings, KMC is inconsistently applied. The highly complex and contextual nature of the environments where medically-dependent babies are cared for is acknowledged. There is a need for health services to explore innovative research approaches, through a social science lens, to assist in the implementation of KMC. This thesis illustrates one such approach. The purpose of this study was to explore and activate improvement of the KMC programme within one NICU in Aotearoa New Zealand using Participatory Action Research (PAR). The research was theoretically informed by Als’ developmental biology and care theories, D’Agata’s Infant Medical Trauma model, and the Foucauldian concept of power/knowledge through a critical feminist lens. A participatory approach was chosen in the hope that transformation of KMC practice would be achieved and embedded within this NICU. In addition, I intended to contribute to the emerging body of evidence calling for the collaboration of all community members toward enhanced quality of KMC. Multiple methods were used to capture data relating to the NICU’s KMC programme through audit, observation and interview of key stakeholders. Project planning included the conventions of PAR generally applied to research using this methodology. Three iterative cycles of exploration, implementation and evaluation of the KMC programme were envisaged within this setting. Active participation with multiple NICU stakeholders was planned for, forming the basis of action-based change and improvement of KMC. However, the three-cycle process was not achieved within the time limitations of my research, with field work finishing at the conclusion of the first exploratory cycle. This thesis describes the unfolding processes of PAR, as well as the inclusion of a secondary discourse analysis and parental perspectives from local and global literature. Key findings showed inconsistently documented KMC and the near-absence of KMC practice for a significant group of babies. Whilst the benefit of KMC was embedded in the understanding of participants, this knowledge did not translate to practice. There was an unrealistic optimism about the functioning of KMC by most of the stakeholders. In addition, participants expressed ambiguity about their programme, contributing to and influenced by suboptimal KMC education and training. A pathway to improvement of their KMC programme was lacking, and the lines of responsibility for it were unclear. This factor undoubtedly contributed to the difficulties of implementing a full PAR project. Whilst parental, staff and organisational factors were found to influence KMC implementation, arguably the greatest effect on the intervention were the power relations inherent within the normative technocratic, biomedical paradigm. Power relations constituting what was considered authoritative knowledge, and who was authorised to speak, impacted on the participatory nature of the research itself. This resulted in the research not proceeding past the first PAR exploratory cycle through to rounds of implementation and evaluation. This thesis describes participatory inquiry into one KMC programme in the high-income NICU setting, through the lenses of multiple participants within the context of Aotearoa New Zealand. These were not previously known. It also provides an example of how Foucauldian- and feminist-informed PAR methodology may be used within the NICU setting for inquiry into KMC, an intervention positioned outside of the normative biomedical framework.</p>

Affective touch is crucial in infant development, particularly in regulating emotional, cognitive, and physiological processes. Preterm infants are often deprived of essential tactile stimulation owing to their early exposure to the external environment, which may affect long-term developmental outcomes. This review aimed to examine the neurobiological mechanisms of affective touch and highlight effective interventions, such as skin-to-skin contact (SSC) and kangaroo care (KC), to promote development in preterm infants. This review summarizes recent studies in the literature on affective touch, the role of C-tactile fibers, and the effects of tactile interventions in neonatal care. Studies were selected based on their relevance to the care and development of preterm infants, with a focus on physiological and neurodevelopmental outcomes. Key interventions, including SSC and massage therapy, are discussed in relation to their effectiveness in the neonatal intensive care unit (NICU). The results suggest that affective touch, mainly through activation of tactile C-fibers, improves caregiver-infant bonding, reduces stress responses, and supports neurodevelopment in preterm infants. Interventions such as SSC and KC have also been shown to improve physiological regulation in these infants, including heart rate, breathing, and temperature control while promoting emotional regulation and cognitive development. Affective touch is a key component of early development, particularly in preterm infants admitted to the NICU. Integrating tactile interventions such as SSC and KC into neonatal care practices may significantly improve long-term developmental outcomes. Future research should explore the epigenetic mechanisms underlying affective touch and further refine tactile interventions to optimize neonatal care.

Aim: To study the knowledge, attitude, and practices of Kangaroo Mother Care (KMC) among eligible postnatal mothers in the postnatal ward (PNW) and neonatal intensive care unit (NICU) of a tertiary neonatal unit in Eastern India. Methods: A cross-sectional survey was conducted among 100 mothers of low-birth-weight babies in our PNW and NICU. As part of the unit protocol, all mothers of eligible babies were counseled about KMC at first contact verbally as well as by using an informative video on KMC. Data was collected using a structured questionnaire after the routine counseling of the mothers on their first visit after delivery. The analysis of the data was done using appropriate statistics. Results: More than three-fourths (83.2%) of mothers had good knowledge of KMC. A good attitude toward using KMC was found in 91.6% of the mothers. Almost all the mothers (98%) knew the correct KMC position, and 12% of mothers had a previous preterm baby and had given KMC. Many mothers felt the small size of the baby, pain after cesarean section, and central or peripheral intravenous lines in the baby were barriers to KMC. Conclusion: The knowledge regarding KMC among mothers whose babies were admitted into the PNW/NICU was good. Though the attitude toward KMC was good, mothers felt there were multiple barriers to initiating KMC.

Kangaroo Mother Care(KMC) is essential for preterm infants and strongly recommended by the World Health Organization. However, national data on KMC implementation in Malaysia are lacking. We aimed to describe current KMC practices in Malaysian hospitals and identify factors influencing its adoption. We conducted a cross-sectional survey using a self-administered online questionnaire. Ninety-three public and private hospitals providing Level II and/or III neonatal care were identified and invited to participate. The questionnaire covered KMC practices, facility availability, eligibility criteria, and documentation. Sixty-nine hospitals(74%) responded, including 48 public and 21 private facilities. Of these, 60(87%) hospitals self-reported implementing KMC (33 regularly, 27 occasionally), most commonly in NICUs and SCNs. Among hospitals implementing KMC, 73% allowed KMC for infants on tube feeds, 71% for those on nasal oxygen, 53% for those on intensive respiratory support, and 68% for infants born <32 weeks gestation. Only 55% documented KMC consistently, 37% had protocols, and 25% reported most staff were trained. Key barriers included limited administrative support, training, infrastructure, and comfort amenities. Logistic regression showed that availability of KMC protocols, front-button blouses, training, and documentation showed a borderline association with regular KMC practice. Among non-implementing hospitals, most cited overcrowding and lack of resources; nearly all expressed a need for training. KMC is practiced in most public and some private Malaysian hospitals, but key gaps remain. Simple measures such as providing front-button blouses, enhancing staff training, and introducing formal protocols can strengthen KMC as routine neonatal care.

Kangaroo care is no longer performed for the initial purpose of maintaining a small baby's body temperature in the developed countries where there are now sufficient medical equipments to keep babies warm. The objectives of kangaroo care in advanced neonatal ICUs have changed to provide benefits such as bonding and attachment, physiologic stability of newborn babies, successful breastfeeding and positive effects on infant development. Kangaroo care is not new to many neonatal nurses, but not every neonatal center is routinely practicing kangaroo care in Singapore. Inadequate nurses' knowledge and lack of guidelines on kangaroo care hinder its practice. The aim of this project was to implement kangaroo care in very low birth weight babies in a systematic and structured approach. The team followed Larrabee's The Model For Evidence-Based Practice Change, used the available evidence on kangaroo care to develop guideline that was specific and suitable for the local setting. The team organized kangaroo care road shows for nurses and parents to create and enhance awareness. Evaluation of the project was done through two audits. The audit tool consisted of correct baby positioning and nursing documentation, with a sample size of 30 episodes. The ages of the babies audited were from 24 to 34 weeks of gestation with their weight ranging from 850 to 1500 g. The compliance rate for correct baby positioning during kangaroo care was 100% for both audits. The compliance rate for nursing documentation improved from 93% in the first post-implementation audit to 96.7% in the second post-implementation audit. The systematic and structured approach in kangaroo care implementation has created awareness among nurses and led to improvements in their knowledge and practices of kangaroo care. The implementation process of kangaroo care has also aided in training the ward Evidence-Based Nursing Unit team members to engage in critical thinking, which ultimately benefited the babies and parents.

Background: Kangaroo Mother Care (KMC) is an evidence-based strategy to provide vital support for preterm or low-birth-weight infants, developed in response to shortages of technological and human resources. It combines qualified, humanized care with biopsychosocial interventions centered on skin-to-skin contact. Objective: To analyze the barriers limiting effective implementation of KMC in neonatal services at maternity hospitals in Luanda, Angola. Development: Although KMC is used globally (in both low- and high-income countries), its application in Luanda remains limited. This setting faces high birth rates and insufficient resources for neonatal care. Continuous, specialized training of nursing staff is identified as a critical factor for adequate care delivery, enabling integrated support for the newborn and family as a unit, and is essential for KMC adoption. Conclusions: KMC represents an effective, humanized approach for immediate neonatal care in Luanda. Urgent training of healthcare staff in caring for preterm mother-infant dyads is fundamental. Furthermore, increasing prenatal KMC awareness among the population may contribute to reducing infant mortality under one year of age.

Background. The Philippine General Hospital (PGH) implemented the Kangaroo Mother Care (KMC) Program in 2014, recognizing its benefits in helping low birth weight (LBW) infants survive.&#x0D; Objective. To determine the acceptability and compliance of the stakeholders to the KMC program after one year from implementation.&#x0D; Method. Data were obtained from the NICU Annual statistics, KMC data forms, logbooks, and questionnaires to the stakeholders-doctors rotating at the NICU, NICU nurses, and mothers enrolled in the KMC program.&#x0D; Results. One year into the KMC program implementation, the KMC enrollment increased from 57% in 2014 to 75% in 2015. All mothers enrolled in the program said that they received their KMC knowledge from the health providers and firmly believed that KMC benefited them and their infants. The mothers also became more confident in taking care of their babies after each KMC encounter. Although only 50% said they would continue KMC at home, 85% proceeded. Furthermore, both doctors and nurses believed that KMC was beneficial to both mothers and infants, decreased hospital cost and nursing workload. KMC provision was 0.5-6 hours/day. Also, less than half of the data forms were accomplished. The KMC program was acceptable to all stakeholders who believed in the benefits of KMC to preterm infants. The mothers were very receptive and continued KMC even after discharge. However, there was sub-optimal engagement provided by the health providers with the mothers. There was also low adherence to recommended duration of KMC per day provided by the mothers. KMC data records were frequently not accomplished. PGH has instituted strategies to improve the KMC implementation by providing dedicated KMC rooms and supplying meals to mothers to increase KMC duration and frequency. A computer-based program for data entry was developed for the health providers, and a dedicated encoder was assigned.&#x0D; Conclusion. KMC acceptability was high among stakeholders. Compliance increased after one year, with enrolment going up to 75%. However, adherence to the recommended KMC duration per day and accomplishment of data forms were still sub-optimal.

Kangaroo mother care practice, knowledge, and perception among NICU nurses in Riyadh, Saudi Arabia.

In this issue of Acta Paediatrica, Linnér et al1 report the thermal performance of immediate and uninterrupted skin-to-skin contact (SSC) for very preterm infants born at a gestational age of 28+0-33+6 weeks. Of the 55 infants, 26 were randomised to receive SSC with a parent and the 29 controls were warmed on a resuscitaire or in an incubator. The infants' body temperature was measured on admission to the neonatal unit and 1 hour after birth. The main finding was that infants in the SSC group had a lower mean body temperature (primary outcome) at both time points than the controls. The two secondary outcomes were similar in both groups, namely duration of respiratory support and breastfeeding status at discharge. The authors concluded that immediate SSC provided a feasible alternative, but there was a significant risk of hypothermia that needed to be addressed. SSC has been proven to provide an optimal care environment that supports numerous vital quality measures of neonatal care, such as improved survival and thermal control, reduced infections, cardiorespiratory stability, parent-infant bonding and interaction, breastfeeding, growth and longer-term development.2, 3 It is indisputably one of the most powerful measures to improve the care of newborn infants and Linnér et al1 should be praised for further investigating important aspects of immediate SSC in very preterm infants. Their study illustrates the difficulty of applying a care method such as SSC in a slightly different setting of clinical practice. SCC makes sense from a heat exchange point of view, and there is robust scientific support for its role in initially stabilising and caring for healthy term neonates.4 However, its value for smaller and sicker neonates clearly relies on how they are managed in detail.5 As the authors point out, early SSC has been demonstrated to be superior in controlling temperature and cardiorespiratory stability in low birth weight infants6 and has already been widely accepted at birth for increasingly lower gestational ages. However, most studies on thermal control during SSC in very preterm or extremely preterm infants have evaluated SSC after the initial postnatal transition.7, 8 Using it for the most vulnerable preterm infants straight after birth is uniquely challenging and presents specific well-known risks, including hypothermia. In particular, the immediate postnatal transition in these patients requires more attention to the onset of respiration, thus requiring a higher level of initial observation and monitoring. During SSC the trade-off between visibility and insulation is obvious and explains the rationale for the widespread use of radiant warmer beds for the initial management of unstable or very tiny infants at birth. Linnér's findings partly disagree with previously published randomised controlled trials3, 6 that demonstrated better thermal stability for preterm infants who received SSC rather than conventional care. The authors adequately explain that methodological limitations related to sample size or the choice of outcome measures might have affected the results and it is conceivable that the slight differences in group characteristics might have influenced the outcomes. Although heat loss will be larger during SSC than when a resuscitaire or incubator is used, I do not think that using SSC for thermal control should be discouraged by the Linner et al1 study. Even though the primary outcome measure, body temperature on admission, effectively detects the inevitable initial drop in body temperature after birth, it should preferably be complemented with body temperature measurements after the first postnatal hour. During SSC heat is exchanged through conduction of heat but since the temperature gradient between parent and infant is small, the efficiency of heat transfer is low and the return to normal body temperature takes time. A previous study9 that analysed the SSC care environment clearly demonstrated that the net heat gain and gradual recovery of body temperature in extremely preterm infants took several hours. Thus, the heat exchange characteristics simply require long enough for SSC to perform at its best. Short and, or, interrupted periods of SSC will result in repeated cold stress and an adversely low body temperature in smaller infants. At the other end of the scale, radiant warmers provide a much higher heat output that can result in a significant risk of overheating, at least in infants that require a long time to stabilise, and particularly when a plastic bag or wrap is used.10 Our knowledge about SSC has rapidly expanded, but some aspects would benefit from further evaluation. Randomised trials are clearly not justifiable or ethical in term or moderately preterm infants, given the apparent advantages of SCC compared with separating the parent-infant dyad for incubator care.2-8 However, the rapidly spreading use of immediate SSC for very preterm infants is very suitable for larger randomised controlled trials. These could include long-term follow-ups of aspects, such as breastfeeding duration and rate, growth, neurological development and the psychological well-being of both parents and infants. However, other options might be preferable for studies that are specifically limited to thermal control of preterm infants during SSC. For example, systematic quality improvement approaches could provide rapid feed-back to healthcare staff. Body temperature, and stability, is relatively easy to measure, while the relative importance of many different influencing factors varies tremendously. Therefore, it is probably wise to focus on quality improvements to optimise SSC before the implementation, and initiation, of randomised trials. Immediate SSC could then be implemented in a stepwise manner beginning with infants born after >32 weeks, before extending SSC to those born at 28-31 weeks. Present knowledge suggests that extremely preterm infants born at less than 28 weeks are probably best stabilised using radiant warmers or incubators, where the drop in body temperature can be limited. This would delay SSC until the infant is in thermal balance. The available science suggests that SSC is feasible and allows adequate thermal control as early as during the first week after birth also for infants at the extremes of gestation.9 Any comprehensive quality improvement initiative for SSC in very or extremely preterm infants should, therefore, take into account how to prevent heat loss and optimise heat gain. There is reasonable evidence to support a number of measures that can be easily adopted (Table 1). These will vary, depending on the infant's status and gestational age and the availability of resources. Thermal control in any newborn infant and setting is not a matter of high-tech vs low-tech care delivery. It is about finding the best compromise and getting the most out of each mode of care. The author has no conflicts of interest to declare. Johan Ågren

This study aimed to (1) determine the effect of neighborhood-level socioeconomic status (SES), which considers the social and physical environment where a person lives, on parental engagement in the Neonatal Intensive Care Unit (NICU) and (2) compare the relationships between parental engagement and individual versus neighborhood-level measures of SES. In this cohort study, parents (n = 45) of premature neonates ≤34 weeks' gestation were assessed at 2 and 6 weeks after birth from December 2017 to October 2019. Neighborhood-level SES was determined using census data per the Association of Maternal and Child Health Programs' methodology, and parents self-reported their education level as an individual-level measure of SES. Data on frequency of engagement in NICU activities, including telephone updates, visitation, providing expressed breastmilk, and participating in kangaroo care, were collected from the electronic medical record. Parent psychosocial factors were assessed using validated surveys. Statistical analysis was performed using Fisher's exact test, t-test, and logistic regression. In multivariate regression analysis, disadvantaged neighborhood-level SES was associated with decreased odds of kangaroo care (OR = 0.16, 95% CI: [0.03-0.89]) and visitation (OR = 0.14, 95% CI: [0.02-0.87]), while lower individual-level SES was not significantly associated with kangaroo care, visiting, calling, or pumping (p > 0.05). Parental engagement was more consistently and significantly associated with neighborhood-level SES than with individual-level SES. Therefore, neighborhood-level SES measures may be more explanatory than individual-level SES measures. Further studies and targeted interventions are needed to address disparities in the frequency of kangaroo care and visitation according to SES. · Parents from disadvantaged neighborhoods are less likely to do kangaroo care and visit the NICU.. · Parent engagement was more significantly associated with neighborhood than with parent education.. · Neighborhood-level SES measures may be more explanatory than individual-level SES measures.. · Interventions are needed to address SES-related disparities in NICU kangaroo care and visitation..

Introduction: The COVID-19 pandemic has significantly impacted healthcare systems worldwide, including neonatal services. The pandemic has disrupted the delivery of neonatal care, leading to challenges in providing essential services to newborns and their families. This review article aims to explore the impact of COVID-19 on neonatal services and identify strategies for mitigating the effects of the pandemic.&#x0D; Methods: A literature search was conducted using PubMed, Embase, and Cochrane Library databases. The search terms used were "COVID-19," "neonatal care," "neonatal services," "prematurity," "low birth weight," and "infant mortality." Articles published between January 2020 and August 2021 were included in this review.&#x0D; Results: The COVID-19 pandemic has reduced the number of antenatal visits, delayed referrals, and decreased access to specialized care for high-risk pregnancies. The pandemic has also disrupted the delivery of essential neonatal care services such as breastfeeding support, kangaroo mother care, and immunization programs. Moreover, there has been an increase in maternal stress and anxiety due to restrictions on visitation policies in neonatal intensive care units (NICUs). These factors have contributed to increased preterm births, low birth weight infants, and infant mortality rates.&#x0D; Conclusion: The COVID-19 pandemic has significantly impacted neonatal services worldwide. Maintaining essential neonatal care services during pandemics is crucial to prevent adverse outcomes for newborns and their families. Healthcare providers must implement strategies to mitigate the effects of the pandemic on neonatal care delivery. These strategies include telemedicine consultations for antenatal visits, home-based follow-up programs for high-risk pregnancies, virtual breastfeeding support groups, and modified visitation policies in NICUs.

AimsNew evidence indicates that Kangaroo Mother Care (KMC) commenced immediately after delivery reduces mortality among neonates weighing 1-1.8kg.1 In order to support the widespread implementation of KMC for these neonates...

The Impact of an Educational Intervention on Newborn Care Practices and Survival Rates in Nigeria: A Mixed Methods Study