Skin-to-skin Contact During the Transfer From the Delivery Room to the Neonatal Intensive Care Unit: Impact on Very Preterm Infants and Their Parents (TRANSPAPNEO)

Skin-to-skin Contact During the Transfer From the Delivery Room to the Neonatal Intensive Care Unit: Impact on Very Preterm Infants and Their Parents

Assessment of Skin-to-skin Contact During the Transfer of Very Preterm Infants From the Delivery Room to the Neonatal Intensive Care Unit : a Randomised Controlled, Non-inferiority, Open-label Trial, in Comparison With Transfer in Incubator

Developmental care are recognized as a standard of care for preterm infants in neonatal intensive care units. Regular skin-to skin contacts during the neonatal stay show short and long-term beneficial effects on preterm infants and their parents. Skin-to-skin contact provides hemodynamic and thermal stability in preterm infants. Regarding parents, skin-to-skin contact sustains the parental bonding, and reduces stress and anxiety related to hospitalization. As a result, early skin-to-skin contact has been associated with an improvement of neurological outcome in very preterm infants. Thermal stability is crucial during the first hour of life in preterm infants. A temperature at admission in the neonatal intensive care unit below 36.5°C or above 37.2°C has been associated with an increase in neonatal morbidity and mortality. Early skin-to-skin contact between a newborn and his/her mother in the delivery room significantly decreases the occurrence of hypothermia below 35.5°C. The practice of skin-to-skin transfer from the delivery room is emerging in France. Pilot studies have been carried out by French neonatal teams that showed the feasibility of this practice in late-preterm, near-term and term infants. Although skin-to-skin contact routinely involves very preterm infants in neonatal intensive care units worldwide, the feasibility and safety of skin-to-skin contact during the transfer from delivery room to the neonatal unit is poorly documented in very preterm infants. Previous data of our team showed that transfer of preterm infants with non-invasive ventilation using skin-to-skin contact was feasible and safe but concerns emerged about the thermal conservation during the procedure. The main hypothesis of this study is that skin-to skin contact during the transfer from the delivery room to the neonatal intensive care unit could prevent heat losses in preterm infants as well as the transfer in incubator. Another hypothesis is that very early skin-to-skin contact could positively influence the neonatal course and the parental experience in the neonatal care unit.

Preterm infants will be transferred using a direct skin-to-skin contact with their father from the delivery room to the intensive neonatal care.

Preterm infants will be transferred in an incubator set to 36°C from the delivery room to the intensive neonatal care.

For the Skin-to-skin Contact (SSC) transfer, the bare-chested father will seat in a wheelchair. Newborns who will wear only a diaper and a cotton cap or noninvasive ventilation headgear will be placed in the kangaroo position against the father's chest to ensure direct contact with the father's skin. Preterm infants with gestational age less than 33 weeks will be wrapped with their father using plastic bags plus warmed cotton towels. More gestationally mature infants will be wrapped with only warmed cotton wraps. The newborn's heart rate, oxygen saturation and skin temperature will be monitored throughout the procedure.

In the incubator group, infants will be transferred after resuscitation in an incubator with air temperature set to 36°C. The newborn will be laid on his/her back in a polyethylene bag with a cap. The newborn's heart rate, oxygen saturation and skin temperature will be monitored throughout the procedure.

Fluctuation in the infant skin temperature between the randomization in the delivery room and the admission in the neonatal intensive care unit (NICU)

Rapid decrease in heart rate less than 100 beats/min that lasts at least 10 secondes during the transfer procedure

First assessment of carbon dioxide partial pressure (pCO2) in the neonatal intensive care unit (NICU)

Practice of skin-to-skin contact in the neonatal intensive care unit (NICU) during the first week of life

Frequency of skin-to-skin contact (Postnatal day and hour), length of each skin-to-skin contact, which parent involves in each skin-to-skin contact episode.

Assessment through a maternal questionnaire: Mother-to-Infant Bonding Scale (MIBS) questionnaire (Mother-to-infant bonding scale - Taylor, 2005). Only the infant's mother will be invited to fill out this questionnaire.

2 time points: i) Between the infant postnatal day 3 and postnatal day 7, and ii) at the infant postnatal day 30 or at the end of the stay in the NICU if this event occur before the postnatal day 30

Parental stress assessed by Perceived Stress Scale (PSS) - Neonatal Intensive Care Unit (NICU) questionnaire (Perceived Stress Scale Neonatal Intensive Care Unit - Miles, 1993). The infant's mother and father will be invited to fill out this questionnaire.

2 time points: i) Between the infant postnatal day 3 and postnatal day 7, and ii) at the infant postnatal day 30 or at the end of the stay in the NICU if this event occur before the postnatal day 30

Parental post-traumatic stress disorder assessed by Perinatal Post traumatic stress disorder Questionnaire (PPQ) - DEMIER, 1996). The infant's mother and father will be invited to fill out this questionnaire.

At the infant postnatal day 30 or at the end of the stay in the NICU if this event occur before the postnatal day 30

Death Intraventricular hemorrhage (maximal grade), Periventricular leukomalacia, Necrotizing enterocolitis (> stade 2 of the Bell classification), Neonatal surgery, Early onset sepsis (onset before postnatal day 2 and > 3 days of intravenous antibiotherapy), Late onset sepsis (Blood culture positive, number of events), Number of red blood cell transfusions, Duration of mechanical ventilation (days). Severe bronchopulmonary dysplasia, Retinopathy of prematurity that requires laser photocoagulation or intravitreal injection of proangiogenic factor, Length of stay in neonatal intensive care unit (days).

Modes of infant feeding that include breastfeeding, breastmilk given through a bottle, artificial formula

Ancillary study: Self-questionnaires to study parents' experience of their infant hospitalization to assess stress at different times.

2 time points: i) Between the infant postnatal day 3 and postnatal day 7, and ii) at the infant postnatal day 30 or at the end of the stay in the NICU if this event occur before the postnatal day 30

Inclusion Criteria: Gestational age < 34 weeks Singleton pregnancy Inborn birth, i.e., in the maternity ward of investigating centres Need of hospitalization in the neonatal intensive care unit Oral and written information of parents and written parental consent to participate in the study (by the father if the mother is unable to participate) Exclusion Criteria: Single parent or homosexual couple Absence of the father in the delivery room Parents not speaking French Skin temperature of the newborn < 36°C at the time of randomization Conditions not allowing the early skin-to-skin contact: omphalocele, gastroschisis, desquamating dermatological conditions (Harlequin syndrome, Collodion) Clinical condition requiring a specific transfer mode according to the pediatrician in the delivery room Parents under legal protection Minor parents